Fish Potter Bolaños, P.C | Employee Potential Client Intake Form

Employee Potential Client Intake Form

First Name
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Last Name
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Phone
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Email:
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Street Address:
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Date Of Birth (mm/dd/yyyy)
Please enter your date of birth.
Emergency Contact 1 (include name, telephone, and address):
Please enter the information for your first emergency contact.
Emergency Contact 2 (include name, telephone, and address):
Please enter the information for your second emergency contact.
Name of Spouse:
Please enter the name of your spouse.
Educational History:
Please enter the name of your spouse.
How did you learn of our law firm?
Please enter how you learned of our firm.
What are/were your dates of employment:
Please enter the date(s) of your employment.
Identify all social media accounts (i.e, Facebook, etc.):
Please enter your social media account(s).
Why are you seeking legal representation? Please be as a detailed as possible and provide dates of incidents:
Please enter your reason for seeking legal representation and any details.
Did you complain about what happened to you to anyone? If so, please provide all details relating to such complaint(s).
Please enter whether you complained about what happened to anyone.
List name and address of your employer/prior employer:
Please enter the name and address of your employer.
Approximate number of employees:
Please enter the approximate number of employees.
Name of your supervisor:
Please enter the name and address of your supervisor.
What were your job duties:
Please enter the duties of your job.
How much were you paid and by what method (salary, hourly, etc)
Please enter the duties of your job.
What discipline/warnings did you receive from employer?
Please enter any discipline or warnings you recevied during your employment.
Current Employer:
Please enter the name of your current employer.
Prior Employment and reasons for leaving:
Please enter the name of your prior employer and reasons for leaving.
If you are claiming any physical or medical injuries, please fill this section out. For each doctor you have seen in the last year, please list the doctor’s name, address, why you were seeing the doctor, and dates of treatment
Please enter any physical or medical injuries.
What are your expectations, i.e., what do you want to see happen through a lawyer?
Please enter the expectations you have; what you want to see happen through a lawyer.
Have you filed any complaints with any government agencies? If so, when?
Please enter whether you have filed any complaints with any government agencies.
Identify all witnesses (including their contract information if possible) and what you think they will say.
Please enter any witnesses and what you think they will say.
List all crimes you have been convicted of (excluding minor traffic):
Please enter any crimes you hav ebeen convicted of.
Have you ever filed for bankruptcy? If so, when?
Please enter whether you have ever filed for bankruptcy.
Any additional information you wish to share?
Please enter any additional information.
Upload a file: