Employee Potential Client Intake Form
  • Please enter your first name.
  • Please enter your last name.
  • Please enter your phone number.
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  • Please enter your email address.
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  • 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 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 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.