1. Client Information
Full Name
*
Date of birth
*
Email
*
Address
Street Address
*
City
*
State
*
Country
*
Country
Postal Code
*
Phone
*
Preferred Contact Method:
*
2. Employment Background
Current or Most Recent Employer
*
Job Title
*
Start Date
*
End Date
Hourly Rate / Salary
Supervisor’s Name
*
Supervisor’s Title
3. Nature of the Employment Issue
Reason for Seeking Legal Help
Wrongful Termination
Discrimination (race, gender, age, disability, etc.)
Harassment (sexual, workplace bullying, etc.)
Wage and Hour Violations (unpaid overtime, missed breaks, etc.)
Retaliation
Contract/Severance Issues
Other
(HIGHLIGHT all that apply)
Brief Description of the Issue:
*
Explain what happened, when, and who was involved.
4. Timeline of Events
Date issue began
*
Date of termination (if applicable)
Has the client filed a complaint with HR?
*
Yes
No
Has the client filed with the EEOC or state agency?
*
Yes
No
Share details of EEOC or state agency filling
5. Supporting Evidence
Documents available (termination letter, emails, pay stubs, contracts, etc.)
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Witnesses (names and contact info, if any)
6. Goals and Expectations
What outcome is the client seeking? (e.g., reinstatement, severance, monetary damages, policy change)
*
7. Additional Notes
Relevant medical issues (if disability is involved)
Prior disciplinary actions
Anything else important to know