Employee Potential Client Intake Form

Our Team has represented hundreds of low wage and elderly clients on a pro bono basis through our volunteer work with Prairie State Legal Services. We love helping out in the community, working to make wrongs right, and taking on important charitable matters. Read below to find out more about what we are up to.

  • Please enter your first name.
  • Please enter your last name.
  • Please enter your phone number.
    This isn't a valid phone number.
  • Please enter your email address.
    This isn't a valid email address.
  • Please enter your address.
  • Please enter your date of birth.
  • Please enter the information for your first emergency contact.
  • Please enter the information for your second emergency contact.
  • Please enter the name of your spouse.
  • Please enter the name of your spouse.
  • Please enter how you learned of our firm.
  • Please enter the date(s) of your employment.
  • Please enter your social media account(s).
  • Please enter your reason for seeking legal representation and any details.
  • Please enter whether you complained about what happened to anyone.
  • Please enter the name and address of your employer.
  • Please enter the approximate number of employees.
  • Please enter the approximate number of employees.
  • Please enter the name and address of your supervisor.
  • Please enter the duties of your job.
  • Please enter the duties of your job.
  • Please enter any discipline or warnings you recevied during your employment.
  • Please enter any discipline or warnings you recevied during your employment.
  • Please enter the name of your current employer.
  • Please enter the name of your prior employer and reasons for leaving.
  • Please enter any physical or medical injuries.
  • Please enter the expectations you have; what you want to see happen through a lawyer.
  • Please enter whether you have filed any complaints with any government agencies.
  • Please enter any witnesses and what you think they will say.
  • Please enter any crimes you hav ebeen convicted of.
  • Please enter whether you have ever filed for bankruptcy.
  • Please enter any additional information.