The employment law client intake form is an important first step to help us in becoming familiar with you and your potential case. It gathers information about a broad range of areas of employment law.
Please fill out the entire form. Even if you do not think a series of questions apply to your situation, you may be surprised. Let me, as a lawyer, help you determine what kind of case you may have.
Brief description of your legal issue.
Please provide the name and address for the employer involved. (To insure our firm has no conflict of interest)
Number of Employees in Company*1-1415-5051-100100+
How were you paid?*HourlySalaryCommissionPiece RateOther
Did you work more then 40 hours per week in the last 3 years?*YesNo
Are you due and owed any unpaid wages?*YesNo
During the last 3 years, where you paid for all hours worked over 40 hours per week at one and one-half times your hourly rate of pay?*YesNoDoes Not Apply
Please check all that apply :
Subjected to sexually hostile work environment.
Discriminated against because of my sex.
Discriminated against because of my disability.
Discriminated against because of my race.
Discriminated against because of my sexual orientation.
Discriminated against because of my religion.
Discriminated against because of my National Origin.
Discriminated against because of my age (over 40).
Retaliated against because I pursued workers compensation benefits.
Retaliated against because I objected to illegal activity or practice at work.
Retaliated against because I refused to engage in illegal activity or practice at work.
Retaliated against because I participated in investigation of illegal activity or practice at work.
Retaliated against or fired because I took Medical leave to care for myself or a family member.
If you have suffered an adverse employment action (such as termination, demotion, failure to promote, suspension, reduction in hours or reduction in pay), please state the reason given by your employer for the adverse action.
If you have suffered an adverse action as described above, please state what you believe to be the reason for the adverse action (such as being in a protected class based on race, sex, national origin, age, disability, religion, sexual orientation or engaging in protected activity such as whistle-blowing, using medical leave or filing a worker’s compensation claim) and identify any evidence you believe supports your claim (such as discriminatory comments or being treated differently than other employees)
If you believe you have been subjected to sexual harassment or subjected to a hostile work environment based upon your being part of a protected class (such as sex, race, age, religion, disability, sexual orientation or national origin), please describe in detail the conduct to which you have been subjected, including any relevant dates.
Have you made a complaint about your situation to any government agency such as the Equal Employment Opportunity Commission or Florida Commission on Human Relations?
If yes, provide the name of the agency, the date you made your complaint, and the final result, if any, of your complaint.
Are any other people involved?
*YesNoDoes Not Apply
If yes, provide names, addresses (if known), and their relationship to you, if any.
If you have any documents that support your case or position please identify the documents and their date.
If you know of documents not in your possession that support your case please identify those documents, their date and location (if known).
Describe how this situation has impacted you.
Describe what you would like to happen to resolve your issue (your preferred outcome).
Have other attorneys worked on this matter or were you referred to our office by an attorney?
If yes, please provide the names and addresses of other attorney and a brief description of their involvement.
Best way to contact you?*EmailPhone
I have read and agree to the following disclaimer: The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form. *
0 + 5 = ? Please prove that you are human by solving the equation *
Mondays - Fridays
9:00 am - 5:00 pm
Appointments after hours and at your home made with prior arrangement.
824 W. Indiantown Road
Jupiter, Florida 33458