intake form - person typing on laptop

Confidential Employment Intake Form – Short

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    Claim your free consultation by filling out this short form and we’ll get back to you as soon as possible to schedule an appointment. Estimated time to complete the form is 5 minutes. All information contained herein is kept strictly confidential.

    Part One – General Questions

    Name*
    Job title(s)
    Telephone*
    State of residence*
    Email*
    Company name
    Approximate dates of employment – From:
    Until (end date):
    Approximate number of employees working for the company:
    Are you a member of a union?
    Do you work for a city, state, or federal agency?
    Have you worked with another law firm on this case?
    Reason for contacting us today:
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    Part Two – Discrimination/Harassment/Wrongful Termination

    1. Are you still working for the company, did you resign, or were you fired?
    2. If fired, what was the reason given by the company for the termination?
    3. Do you believe you were treated differently because of your race, religion, color or other protected category? (Select all that apply)
    If other, please explain:
    4. Did you have a disability or medical condition for which you requested an accommodation from the company?
    5. Did you take or request time off from work for medical or family reasons?
    6. Did you ever report illegal activity to anyone within the company (such as unsafe work conditions) or say you wouldn’t do something you thought was illegal?
    7. Did you make any complaints to management about the treatment you experienced?
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    Part Three – Potential Wage Claims

    1. Were you paid overtime if you worked more than 8 hours/day or 40 hours/week?
    2. Did you receive bonuses or commission payments? (Your OT may not have been paid properly.)
    3. Did you work off the clock at all – i.e., before you clocked-in or after you clocked-out?
    4. Were you required to pass through a security screening or bag check before or after work?
    5. Were you able to take 30-minute uninterrupted meal breaks within the first 5 hours of work?
    6. Could you leave the premises during your meal break?
    7. Were you required to keep a walkie-talkie or cell phone on during your breaks?
    8. If you paid for employment-related expenses (e.g., shirts), were you reimbursed for them?
    By submitting below, you confirm that you understand that this form does not create an attorney-client relationship between you and the Hekmat Law Group and that no such relationship exists unless we sign a written agreement to work together. If you do not hear from us within two business days, please call us at (424) 888-0848. If you have any deadlines approaching, we cannot guarantee that we will respond in time to assist you and you should therefore take immediate action to avoid missing any such deadlines.