Where To Turn When You’ve Been Wronged Home » Employment Intake Form Employment Intake Form BASIC INFORMATIONCurrent Date MM slash DD slash YYYY Name First Last Race Date of Birth MM slash DD slash YYYY National Origin Social Security Number Drivers License Number State CONTACT INFORMATIONAddress Line 1 Address Line 2 City State Zip Home Phone Cell Phone Work Phone Email Address(Required) SPOUSE/SIGNIFICANT OTHERSpouse/Other Name Home phone Cell phone Work phone REFERRALWho Referred You to Our Office? MARRIAGES/DIVORCESDatePlace of Marriage Spouses Name How Marriage Terminated DatePlace of Termination DatePlace of Marriage Spouses Name How Marriage Terminated DatePlace of Termination DatePlace of Marriage Spouses Name How Marriage Terminated DatePlace of Termination CHILDRENName Current Age Residing With Name of Other Parent Name Current Age Residing With Name of Other Parent Name Current AgeR Residing With Name of Other Parent Name Current Age Residing With Name of Other Parent Name Current Age Residing With Name of Other Parent EDUCATIONAL HISTORYDate From/To School City/State Degree Obtained Date From/To School City/State Degree Obtained Date From/To School City/State Degree Obtained Date From/To School City/State Degree Obtained EMPLOYMENT HISTORY (Current/Most Recent Employer First)Business Name Employed FROM Employed TO Address Address 2 city state zip Reason For Leaving Reason For Leaving Business Name Employed FROM Employed TO Address Address 2 City state Zip Reason For Leaving Reason For Leaving Business Name Employed FROM Employed TO Address Address 2 City state zip Reason For Leaving Reason For Leaving Business Name Employed FROM Employed TO Address Address 2 City state zip Reason For Leaving Reason For Leaving INFORMATION REGARDING YOUR CLAIMThis is the individual or business that you believe discriminated against you or treated you wrongly. Business name/individual Business/individual phone Business HR Email ATTACH A COPY OF YOUR W2 AND OR PAY STUB FOR EMPLOYER VERIFICATION Drop files here or Select files Max. file size: 256 MB. business/individual Address business/individual address 2 business/individual city business/individual state business/individual zip Business County Number of Employees Your position supervisor Type Of Discrimination Race/Ethnic Origin National Origin Age Sex (Gender) Disability/Handicap Marital Status Religion Retaliation (Select All That Apply)Date of Last Act of Discrimination/Retaliation List all person(s) that you believe discriminated against you or treated you wrongly.NAME RACE JOB TITLE NAME RACE JOB TITLE NAME RACE JOB TITLE NAME RACE JOB TITLE WHEN & WHYName of person who hired you Date of Hire Name of person who terminated you Date of Termination Did/does this employer evaluate your job performance in writing? If so, what rating(s) did you receive?Have you ever received any awards or other special recognition from this employer? If so, describe the award or recognition and state the date on which you received it.If you are no longer with this employer, did you resign or were you fired?If you were fired, state the reason given by your employer. If you resigned, state the reason you gave to your employer. IF YOU GAVE OR WERE GIVEN A TERMINATION OR RESIGNATION LETTER, ATTACH A COPY.Max. file size: 256 MB.DESCRIPTION OF INCIDENTIn the space provided below, please describe in your own words (and in detail) the events that have led you to believe that you were discriminated against or treated wrongfully by this employer/individual.HiddenIn the space provided below, please describe in your own words (and in detail) the events that have led you to believe that you were discriminated against or treated wrongfully by this employer/individual (cont.)In the space provided below, please describe in your own words (and in detail) the events that have led you to believe that you were discriminated against or treated wrongfully by this employer/individual.HiddenIn the space provided below, please describe in your own words (and in detail) the events that have led you to believe that you were discriminated against or treated wrongfully by this employer/individual (cont.)FOLLOW-UP QUESTIONSIn your own opinion, WHY were you treated differently? Include names of people treated better than you. Include names of people treated better than you. Include co-workers who were treated more favorably and how they were treated better. NAME | GENDER | JOB TITLE | RACE | AGE | HOWNAME | GENDER | JOB TITLE | RACE | AGE | HOWIf you have been terminated who is now doing your job duties or who replaced you Were you reprimanded (verbal, written, suspension, demotion, etc.) by this employer? If so, describe each incident of reprimand, including the date on which it occurred.Was/is your job performance or behavior criticized by this employer or any of your supervisors or coworkers? If so, describe each criticism in detail.Do you know if other employees who have committed or been accused of the same behavior as you who were treated differently by your employer (i.e. not reprimanded like you were)? If so, give complete details regarding each employee including name, date, and what the employee did.FOLLOW-UP QUESTIONS - EMPLOYMENT-RELATED ONLY (continued)Did you complete a job application and/or résumé for this employer? If so, was ALL information in that application or résumé truthful? If not, provide details or any other information that was inaccurate, incomplete, or untrue.Have you ever been reprimanded by any OTHER employer? If so, state the employer, date of reprimand, what you were reprimanded for, and any punishment you received.Have you ever been fired from any job, other than as described above? If so, provide complete details including the employer’s name, the date you were fired, and why you were fired.Have you ever been fired (above question) continued.What damages do you believe you have suffered as a result of what this employer did to you? Please be specific regarding wages you feel you have lost, money you have spent, mental or emotional injuries you believe you have received.If you no longer work with this employer, and if you included lost wages as part of your answer above, list all money you have made from any source since leaving this employer.OTHER GENERAL INFORMATIONAnswer the following questions to the best of your ability. If your answer to ANY of these questions is YES please explain below when prompted.1. Have you previously hired or consulted with a lawyer concerning this problem? yes no 2. Have you previously claimed that any person, business, or employer has discriminated against you? yes no 3. Have you participated in grievance proceedings? yes no 4. Have you ever filed internally with the EEO for this employer? yes no 5. Have you ever filed a formal or informal claim of discrimination with regard to THIS employer with the FCHR or EEOC? If so, attach a copy of all documents filed or received from FCHR and EEOC. yes no 6. Have you ever filed a formal or informal claim of discrimination with regard to ANY other employer with the FCHR or EEOC? yes no 7. Have you ever filed a formal or informal claim of discrimination with any other administrative agency or any court? yes no 8. Have you otherwise sued anyone or been sued by anyone (except divorces)? yes no 9. Have you ever been diagnosed with a mental illness or disability? yes no 10. Have you ever been hospitalized or confined for mental illness or disability? yes no 11. Have you ever been adjudicated incompetent? yes no 12. Do you suffer from serious physical illness or disability? yes no 13. Are you currently taking any prescription medications? yes no 14. Have you previously (during the period of your claim) taken prescription medication? yes no 15. Do you regularly use drugs or alcohol? yes no 16. Have you ever been treated for drug or alcohol abuse? yes no 17. Have you ever been rendered totally or partially disabled? yes no 18. Have you ever applied for disability compensation benefits? yes no 19. Have you ever applied for or received unemployment compensation benefits? yes no 20. Have you ever applied for or received workers’ compensation benefits? yes no 21. Have you ever been arrested? yes no 22. Have you ever been convicted of a felony or misdemeanor? yes no 23. Are you receiving disability, social security, AFDC (food stamps or “welfare checks” or other social assistance? yes no 24. Do you or did you have retirement benefits associated with your current or former job? yes no 25. Have you ever served in the military? yes no 26. Have you ever filed bankruptcy? yes no 27. Do you have any plan or intention to file bankruptcy? yes no 28. To your knowledge, have you received any bad or negative employment references from the employer that you believe discriminated against you? yes no 29. Have you ever filed a complaint or grievance with regard to any lawyer who provided legal services to you? yes no 30. Have you ever hired a lawyer to represent you and terminated the lawyer’s services before representation was complete? yes no 31. During the period in which you claim you were discriminated against, were there any other stressful events in your life, such as births, deaths, divorces, marriages, significant problems with your children or family, criminal acts against you, etc.? yes no 32. Have you received treatment by any medical or mental health professional as a result of the discrimination about which you are complaining? yes no 33. Have you received treatment by any mental health professional concerning any matter other than the discrimination about which you are complaining? yes no 34. Have you given any verbal, written, or recorded statements to any person regarding your discrimination/retaliation claim? yes no 35. Have you ever been accused by any employer of dishonesty, such as theft or lying? yes no 36. Have any of our lawyers at this firm represented you or anyone related to you? yes no ANSWERS TO OTHER GENERAL INFORMATION QUESTIONSIf your answer to any of the previous questions is YES, please explain below with the Number of the Question first.Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation Question NumberExplanation WITNESS LISTUSE THIS SPACE to describe all persons that you believe have knowledge regarding your claim of discrimination. Include people you think will support you and people you think are against you. Witness Name Witness Race Witness Type Friendly Hostile Neutral Witness Position/Relationship Witness Address Witness Address 2 Witness City Witness State Witness zip Witness home phone Witness cell phone Witness work phone Witness 2Witness Name Witness Race Witness Type Friendly Hostile Neutral Witness Position/Relationship Witness Address Witness Address 2 Witness home phone Witness cell phone Witness work phone Witness City Witness State Witness zip Witness 3Witness Name Witness Race Witness Type Friendly Hostile Neutral Witness Position/Relationship Witness Address Witness Address 2 Witness home phone Witness cell phone Witness work phone Witness city Witness State Witness zip Witness 4Witness Name Witness Race Witness Type Friendly Hostile Neutral Witness Position/Relationship Witness Address Witness Address 2 Witness home phone Witness cell phone Witness work phone Witness city Witness State Witness zip Witness 5Witness Name Witness Race Witness Type Friendly Hostile Neutral Witness Position/Relationship Witness Address Witness Address 2 Witness home phone Witness cell phone Witness work phone Witness city Witness State Witness zip Witness 6Witness Name Witness Race Witness Type Friendly Hostile Neutral Witness Position/Relationship Witness Address Witness Address 2 Witness home phone Witness cell phone Witness work phone Witness city Witness State Witness zip Witness 7Witness Name Witness Race Witness Type Friendly Hostile Neutral Witness PositionRelationship Witness Address 1 Witness Address 2 Witness home phone Witness cell phone Witness work phone Witness city Witness State Witness zip Witness 8Witness Name Witness Race Witness Type Friendly Hostile Neutral Witness Position/Relationship Witness Address Witness Address 2 Witness home phone Witness cell phone Witness work phone Witness city Witness State Witness zip Wintess 9Witness Name Witness Race Witness Type Friendly Hostile Neutral Witness PositionRelationship Witness Address Witness Address 2 Witness home phone Witness cell phone Witness work phone Witness city Witness State Witness zip Witness 10Witness Name Witness Race Witness Type Friendly Hostile Neutral Witness Position/Relationship Witness Address Witness Address 2 Witness home phone Witness cell phone Witness work phone Witness city Witness State Witness zip Witness 11Witness Name Witness Race Witness Type Friendly Hostile Neutral Witness Position/Relationship Witness Address Witness Address 2 Witness home phone Witness cell phone Witness work phone Witness city Witness State Witness zip Witness 12Witness Name Witness Race Witness Type Friendly Hostile Neutral Witness Position/Relationship Witness Address Witness Address 2 Witness home phone Witness cell phone Witness work phone Witness city Witness State 3_16 Witness zip_27 Important Document InformationPlease list the name/info of the documents and who has itDocument Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Document Who has it Signature and Current DateYour Name (Signature)(Required) If you are done, add your signature to submitDATE PhoneThis field is for validation purposes and should be left unchanged.
