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Where To Turn When You’ve Been Wronged

Contact Marie A. Mattox, P.A.

While this website provides general information, it does not constitute legal advice. The best way to get guidance on your specific legal issue is to contact a lawyer. To schedule a meeting with an attorney, please call the firm or complete the intake form below.

Employment Intake Form

BASIC INFORMATION

MM slash DD slash YYYY
Name
MM slash DD slash YYYY

CONTACT INFORMATION

SPOUSE/SIGNIFICANT OTHER

REFERRAL

MARRIAGES/DIVORCES

CHILDREN

EDUCATIONAL HISTORY

EMPLOYMENT HISTORY (Current/Most Recent Employer First)

INFORMATION REGARDING YOUR CLAIM

This is the individual or business that you believe discriminated against you or treated you wrongly.
Drop files here or
Max. file size: 256 MB.
    Type Of Discrimination
    (Select All That Apply)

    List all person(s) that you believe discriminated against you or treated you wrongly.

    WHEN & WHY

    If you were fired, state the reason given by your employer. If you resigned, state the reason you gave to your employer.
    Max. file size: 256 MB.

    DESCRIPTION OF INCIDENT

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    FOLLOW-UP QUESTIONS

    NAME | GENDER | JOB TITLE | RACE | AGE | HOW

    FOLLOW-UP QUESTIONS - EMPLOYMENT-RELATED ONLY (continued)

    OTHER GENERAL INFORMATION

    Answer 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?
    2. Have you previously claimed that any person, business, or employer has discriminated against you?
    3. Have you participated in grievance proceedings?
    4. Have you ever filed internally with the EEO for this employer?
    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.
    6. Have you ever filed a formal or informal claim of discrimination with regard to ANY other employer with the FCHR or EEOC?
    7. Have you ever filed a formal or informal claim of discrimination with any other administrative agency or any court?
    8. Have you otherwise sued anyone or been sued by anyone (except divorces)?
    9. Have you ever been diagnosed with a mental illness or disability?
    10. Have you ever been hospitalized or confined for mental illness or disability?
    11. Have you ever been adjudicated incompetent?
    12. Do you suffer from serious physical illness or disability?
    13. Are you currently taking any prescription medications?
    14. Have you previously (during the period of your claim) taken prescription medication?
    15. Do you regularly use drugs or alcohol?
    16. Have you ever been treated for drug or alcohol abuse?
    17. Have you ever been rendered totally or partially disabled?
    18. Have you ever applied for disability compensation benefits?
    19. Have you ever applied for or received unemployment compensation benefits?
    20. Have you ever applied for or received workers’ compensation benefits?
    21. Have you ever been arrested?
    22. Have you ever been convicted of a felony or misdemeanor?
    23. Are you receiving disability, social security, AFDC (food stamps or “welfare checks” or other social assistance?
    24. Do you or did you have retirement benefits associated with your current or former job?
    25. Have you ever served in the military?
    26. Have you ever filed bankruptcy?
    27. Do you have any plan or intention to file bankruptcy?
    28. To your knowledge, have you received any bad or negative employment references from the employer that you believe discriminated against you?
    29. Have you ever filed a complaint or grievance with regard to any lawyer who provided legal services to you?
    30. Have you ever hired a lawyer to represent you and terminated the lawyer’s services before representation was complete?
    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.?
    32. Have you received treatment by any medical or mental health professional as a result of the discrimination about which you are complaining?
    33. Have you received treatment by any mental health professional concerning any matter other than the discrimination about which you are complaining?
    34. Have you given any verbal, written, or recorded statements to any person regarding your discrimination/retaliation claim?
    35. Have you ever been accused by any employer of dishonesty, such as theft or lying?
    36. Have any of our lawyers at this firm represented you or anyone related to you?

    ANSWERS TO OTHER GENERAL INFORMATION QUESTIONS

    If your answer to any of the previous questions is YES, please explain below with the Number of the Question first.

    WITNESS LIST

    USE 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 Type

    Witness 2

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    Wintess 9

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    Witness 12

    Witness Type

    Important Document Information

    Please list the name/info of the documents and who has it

    Signature and Current Date

    If you are done, add your signature to submit
    This field is for validation purposes and should be left unchanged.

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