Intake Questionnaire

* = required
* Name:
Address:
City:
State:
Zip Code:
Telephone:
* E-mail:
How did you learn about
this office?
Name of employer:
In which city do or did you work?
In which state do or did you work?
CA Other

Number of local employees:
Current or most recent position:
How long employed?
Type of Wage:

Amount of Wage:
Did you work over 40 hours per week?
If Yes;
How many hours per week did you work on average?
Did you get paid for your overtime?
Did you get paid breaks if you worked over 6 hours in a day?
If you are not now employed, under what circumstances did you leave?
If you quit or were terminated, date of quit or termination?
Is your leaving your employment what is motivating you to contact an attorney?
If you were terminated or laid off, what was the reason your employer gave you (even if you do not believe it)?
If you do not believe your employer’s reason, what do you think the real reason was?
If there a reason other than or in addition to your termination, what is the situation that is leading you to contact an attorney?
If your complaint is about unpaid wages, what kind of wages are due?
If harassment, describe the nature of the harassment?
What is the harasser's position? i.e. co-worker, supervisor
What do you think is motivating the harassment?
Did you complain about the harassment?
If yes, to whom did you complain? (identified by position; i.e. my supervisor)
What do you want the lawyer to do for you?
Are there any other comments you think are important for the lawyer to know?