Employment intake questionnaire

Submit the form below so we have context before you speak with intake. Submission does not establish an attorney–client relationship. For urgent questions, call (800) 566-4868.

Note: Replace the Web3Forms access key placeholder in this form (hidden field access_key) with your real key from web3forms.com , then redeploy—or call (800) 566-4868.

Your contact information

First name

Last name

Phone number

Employer & job

What company do you work for (or worked for)?

Where is the company located? (city and state)

Number of employees Approximate total is fine.

Start date of employment

End date of employment If still employed, use today’s date and explain below.

Rate of pay

Hours per day typically worked

Hours per week typically worked

Pay stubs & breaks

Did you receive a pay stub showing hours worked with every paycheck?

Yes No Not sure

Did you receive a 30-minute uninterrupted meal break for every roughly 5 hours worked?

Yes No Not sure

Did you receive a 10-minute uninterrupted rest break for roughly every 4 hours worked?

Yes No Not sure

Termination

Were you terminated?

Yes No (still employed, quit voluntarily, etc.)

Separation or ongoing situation Describe what occurred, including approximate dates and what your employer stated (termination, resignation, corrective action, etc.).

If you were terminated, why do you believe it was wrongful?

Anything else we should know before we talk?

Termination & retaliation

Discrimination

Harassment

Wage & hour

Leave & accommodation

Employment intake questionnaire