Employment Questionnaire

Please complete our intake questionnaire to confidentially tell us about your case. Please note that we are limited in the types of employment cases we handle. Generally speaking the clients we represent have the following in common: 1) They been fired due to illegal discrimination (e.g., sex, race, disability, age, military status, LGBTQ+ status or another protected status) or retaliation for reporting discrimination, protected harassment or illegal activity, or in connection with taking or requesting FMLA leave or a reasonable accommodation of a disability, and 2) They are currently out of work or experienced a significant period of time out of work, and have not obtained comparable employment, and have significant lost earnings as a result of the termination.

Name *
Phone *
Email *
Address *
How did you hear about us? *
Provide the name and address of your employer. *
Provide your dates of employment and rate of pay. *
What is the date(s) of the adverse employment action that you are contacting us about? *
State how your employer discriminated against you or harassed you because of your protected status. *
If you are claiming retaliation, what was the date of your complaint, the specific complaint you made, and what you claim to be the retaliation as a result. *
Do you have a new job? If yes, when did you start and what is your rate of pay? *
Have you filed any complaints regarding the allegedly improper conduct (i.e. EEOC, New York State Division of Human Rights, Department of Labor, etc.)? If so, when? Have any findings been issued? *
Have you ever been convicted of a crime?* If yes, please describe the conviction. *
Have you ever been a party to a lawsuit? *
Have you spoken with any other attorneys about this? * No Yes

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