Intake Form

Employer and location:

Employment Start Date

Occupation/Position:

What was the number of hours you worked each day?:

How many days per week did you work?:

Wrongful Termination

Wage and Hour Violation

Discrimination(Specify, i.e. race, sex, disability):

Protected Characteristics:

Race/ National Origin (Specify):

Did you receive your payments on a weekly or biweekly basis?

Have you secured new employment? If so, on what date did you begin, and what is your current pay rate?

How Long Were You employed?

What was your beginning and final payment rate?

Date of Termination:

Do you have it in writing?
Yes No

Did you get your rest breaks and meal breaks?

What are the circumstances surrounding the termination?

Kindly provide a specific timeline of events, beginning from your start date of employment through to your last day or the date of the adverse employment action. Include information, such as exact dates, the name of the individual responsible for the adverse action, names of witnesses, and the names of anyone to whom you reported your concerns.

Did you ever complain about anything at work? And if so, in writing?

Any witnesses? If so, do you have their contact information?

Did you receive an employee handbook?

Were you ever disciplined or given warnings? If so, when? Write ups.

Are you applying for unemployment benefits?

What is your current emotional state?

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