Client Intake Form (Page 8 of 9) in pdf

Client Intake Form - Employment Law…8 of 9

vi.

Telephone:______________________________________________________

vii.

Name: _________________________________________________________

viii.

Address: _______________________________________________________

ix.

Telephone:______________________________________________________

Were you required to take any medication for emotional problems related to the

incident? If so, please describe:

_____________________________________________________________________

6. Has this employment action affected your physical health?

__________________________________________________________________________

_________________________________

What was the nature of these problems?

_____________________________________________________________________

Did you consult a medical doctor? ( ____ ) Yes ( ____ ) No

_____________________________________________________

Name:

ii.

___________________________________________________

Address:

iii.

__________________________________________________

Telephone:

_____________________________________________________

iv.

Name:

___________________________________________________

Address:

vi.

__________________________________________________

Telephone:

_____________________________________________________

vii.

Name:

viii.

___________________________________________________

Address:

ix.

__________________________________________________

Telephone:

Client Intake Form Page 8