Discrimination and harassment are against the law in many areas of our lives. One of the most common arenas for discrimination and harassment is the workplace. If you feel you have been discriminated against or harassed by your employer or a co-worker, you will want an experienced attorney to represent your interests. During your first meetings with your attorney, you will need to provide a great deal of information about yourself and your claim. This intake form may give you an idea of what type of information your attorney will need. For example, your attorney will need to know about your family in order to develop an understanding of whether the harassment or discrimination has had any effect on your ability to care and provide for your loved ones.
Full Legal Name: _____________________________
Gender: ____________________________
Date of Birth: _______________________
Race/Nationality: ____________________
Religion: ___________________________
Social Security Number: __________________
Address: _______________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Length of Time at that Address: _______ years Previous Address(es) (for last 10 years): ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
Home Telephone Number: ____________________
Work Telephone Number: ____________________
Facsimile Number: _______________________
E-mail Address: _________________________
Former Name(s): ____________________ ____________________
Marital Status: __________________________
Previous Marriage(s): Yes ____ No ____ Ended By?______________Children
Name Date of Birth Living at Home?
_______________ _________ _______________
_______________ _________ _______________
_______________ _________ _______________
_______________ _________ _______________
Employer at Time of Discrimination or Harassment: ______________ ____________________________________________________________
Job Position/Title at Time of Discrimination or Harassment: ________
Employer’s Address ________________________________________ ____________________________________________________________ ____________________________________________________________
Length of Time with Employer: _______ years ________months
Date of Hire: ___________________________
If Terminated, Date of Termination: _____________________
What was the explanation given for your termination? ____________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
Previous Employer(s) (for last 10 years) _______________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
Gross Monthly Income at Time of Termination: $________________
Other Income at Time of Termination, if any: __________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
Benefits Provided by Employer: ______________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
Date(s) of Harassment or Discrimination _______________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
Description of Harassing or Discriminatory Actions Taken Against You ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
Was anyone else treated similarly? __________________
If Yes, who? _____________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
Who harassed you or discriminated against you? ________________ ____________________________________________________________
What is that person’s job title or description? ___________________
Is he or she considered to be your supervisor? _________________
Was anyone else present at the time of the discriminatory or harassing act? ___________ ___________________________________________________________ ___________________________________________________________
Who was your immediate supervisor at the time? _______________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Did you report the harassment or discrimination to anyone? _______
If Yes, to whom? _________________________________________ ____________________________________________________________ ____________________________________________________________
What was their response? __________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Was a written report made? ______________________
If Yes, do you have a copy of it? ____________________
Were you ever given an employee handbook ? ________________
Do you have a copy of it? _________________________
If Yes, does it contain an anti-harassment or anti-discrimination policy? ________ ___________________________________________________________
Have you ever seen a copy of an anti-harassment or anti-discrimination policy in your workplace? ______________
If Yes, explain: __________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Since the harassment or discrimination, have you spoken or had any contact with the person who harassed you or discriminated against you? __________________
If Yes, explain: __________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Have you ever been disciplined by your employer, for any reason? __________________
If Yes, explain: __________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Have you ever been harassed or discriminated against in other employment? __________
If Yes, explain: __________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Was a lawsuit filed? ______________
If Yes, what was the outcome? _____________________________
_______________________________________________________ ___________________________________________________________ ___________________________________________________________
If you were terminated or left your employment, have you found a new job? __________
Name of Present Employer _______________________________
Address of Present Employer _____________________________
_____________________________________________________
Current Immediate Supervisor ____________________________
_____________________________________________________
Current Job Position/Title ________________________________
_____________________________________________________
Current Gross Monthly Income ___________________________
Benefits Provided by Current Employer _____________________
_____________________________________________________
_____________________________________________________
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Have you ever been arrested? ______________________
If Yes, explain:________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________
Are You in Good Health? ____________________________
Explain all current and chronic illnesses, past and future surgeries, medications you are currently taking, and other relevant health information: ___________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________
Have you ever been told that you have a physical or mental disability? _______________
If Yes, explain: _______________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________
Do you have a history of alcohol or drug abuse? ____________
If Yes, explain: _______________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________
Other Important Information ____________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________
Questions to Ask My Attorney ___________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________
