Employment Case Intake

Employment Case Evaluation

Tell us about your employment situation and we will get back to you as soon as possible regarding whether we are able to assist you. There is no charge to submit, and the information you share is confidential. Submitting this form does not create an attorney-client relationship.

First Name *

Last Name *

Phone *

Email *

Street Address

City

State

Zip

Pronouns

How did you hear about us?

Reason for contact — briefly describe what happened *

What outcome are you hoping for in this matter?

Employer's Name

Do you still work here?

Employer's Street Address

Employer's City

Employer's State

Employer's Zip

Have you signed an arbitration agreement with this employer?

Number of Employees

Job Title / Position

Pay / Salary Amount

Years Employed

Have you filed for unemployment?

Did you receive unemployment?

Did you appeal your denial of unemployment?

Unemployment Denial Details

Date Filed for Unemployment

Upload Unemployment Documents

Max 5 files, 10MB each. Accepted: pdf,doc,docx,png,jpg,jpeg,txt

Have you applied for any other jobs?

Were you discriminated against or harassed?

Other (please specify)

Describe the discrimination or harassment

Did you file a charge of discrimination with the EEOC, MCHR, KHRC, or similar agency?

EEOC / MCHR / KHRC Details

Have you received a Notice of Right to Sue?

Date of Notice of Right to Sue

Have you filed a lawsuit regarding this matter?

Have you ever reported discrimination, harassment, or other misconduct to HR or management?

Did your employer treat you negatively because you reported misconduct?

Retaliation Explanation

Did you ever work time for which you were not paid?

Unpaid Time Explanation

Were you terminated?

Date of Termination

Upload Letter of Termination

Max 3 files, 10MB each. Accepted: pdf,doc,docx,png,jpg,jpeg

Were you suspended?

Suspension 1

Date of Suspension

Length of Suspension

Name of Person Who Suspended You

Reason for Suspension

Resolution of Suspension

Upload Suspension Documents

Max 5 files, 10MB each. Accepted: pdf,doc,docx,png,jpg,jpeg,txt

Did you have a Performance Improvement Plan (PIP)?

Why did you have a Performance Improvement Plan?

Date of Performance Improvement Plan

Who oversaw the Performance Improvement Plan?

How was the Performance Improvement Plan resolved?

Upload PIP Documents

Max 5 files, 10MB each. Accepted: pdf,doc,docx,png,jpg,jpeg,txt

Did you have performance reviews?

Performance Review Details

Upload Performance Review Documents

Max 5 files, 10MB each. Accepted: pdf,doc,docx,png,jpg,jpeg,txt

Did you have any write-ups or other disciplinary actions?

Write-Ups Details

Upload Write-Up Documents

Max 5 files, 10MB each. Accepted: pdf,doc,docx,png,jpg,jpeg,txt

Have you taken time off for any medical condition or FMLA leave?

Leave Event 1

Date / Time of Leave

Number of Work Days Missed

Description / Reason for Leave

Does your employer provide paid sick time?

Did your employer provide you with any notice regarding your sick leave rights?

Did your employer do anything negative to you because you used sick time?

Describe the employer's reaction to your use of sick time

Event 1

Date of Occurrence

Approximate date?

What happened?

Do you have additional documents related to your matter?

Upload Additional Documents

Max 10 files, 10MB each. Accepted: pdf,doc,docx,png,jpg,jpeg,txt

Are there any witnesses you believe could provide evidence to support your claims?

Witness 1

First Name

Last Name

Phone

Email

What did this witness observe?

Employment Case Evaluation

Please verify your contact info: