Employment Questionnaire

Please complete our intake questionnaire to confidentially tell us about your case.

Thank you for contacting us. We will get back to you shortly.

Please complete all required fields below.

• Name *
• Phone *
• Email *
• Address
• How did you hear about us?
• Facts (Why did you contact us? - Be sure to include relevant dates)
• Provide the name and address of your current or former employer (the alleged wrongdoer), and provide names of any employees who you claim committed any wrongdoing.
• How long have you been or did you work for the company? What was your most recent position? What was your most recent salary or hourly wage?
• Describe why you think you were the victim of discrimination or improper conduct (i.e. age, gender, disability, race, pregnancy, medical leave, etc.). Also please provide the names and addresses of any witnesses that you believe are or may be helpful.
• What was the date of the action that you are contacting us about? *
• If you have received any medical treatment or counseling as a result of the incident please provide the names, addresses and dates of treatment for any medical providers.
• If you were terminated have you found new employment? Where, at what salary and what are the responsibilities of the position? If the answer is no, have you looked for other employment? Where and when?
• If you were not terminated, explain how you were damaged as a result of the improper conduct.
• 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 diagnosed or treated for a psychological condition that would impact your ability to accurately and truthfully recall events. If so please briefly explain below.
• Have you ever been a party to a lawsuit?