Client Intake Form (Page 9 of 9) in pdf

Client Intake Form - Employment Law…9 of 9

Were

you

required

take

medication?

so,

please

describe:

___________________________________________________________________________

7. Have you incurred any medical expenses, as a result of the employment dispute, which are not

covered by insurance? If so, describe these expenses:

_________________________________________________________________________________

8. What is your wage loss at the present time?

_________________________________________________________________________________

9. What nonfinancial losses or injuries have you and your family suffered as a result of the employer's

actions?

_________________________________________________________________________________

10. Have you received all the salary, bonuses, vacation pay, commissions, and other compensation

due you? If not, what is due?

_________________________________________________________________________________

11. What other economic losses have you suffered in relation to the employment dispute (e.g., stock

options, profit-sharing, lost and/or reduced wages, etc.)?

_________________________________________________________________________________

Dated:______________________________

_____________________________________________

Client Signature

Client Intake Form Page 9