{"id":357772,"date":"2016-04-04T10:45:26","date_gmt":"2016-04-04T15:45:26","guid":{"rendered":"https:\/\/content.findlaw-admin.com\/ability-law\/employment\/legal-help-and-resources\/attorney-intake-form-facing-discrimination-harassment-at-work.html"},"modified":"2017-12-26T13:33:50","modified_gmt":"2017-12-26T18:33:50","slug":"attorney-intake-form-facing-discrimination-harassment-at-work","status":"publish","type":"page","link":"https:\/\/www.findlaw.com\/employment\/legal-help-and-resources\/attorney-intake-form-facing-discrimination-harassment-at-work.html","title":{"rendered":"Attorney Intake Form: Facing Discrimination & Harassment At Work"},"content":{"rendered":"\n
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Attorney Intake Form: Facing Discrimination & Harassment At Work<\/h1>\n
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Created by FindLaw’s team<\/a> of legal writers and editors<\/i><\/p>\n\n | Last updated\n

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The last updated date refers to the last time this article was reviewed by FindLaw or one of our contributing authors<\/a>. We make every effort to keep our articles updated. For information regarding a specific legal issue affecting you, please contact an attorney in your area<\/a>.<\/em><\/p>\n\n <\/div>\n <\/details>\n<\/section>\n

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<\/a>. 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<\/a>, 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.<\/p>\n

Full Legal Name: _____________________________<\/p>\n

Gender: ____________________________<\/p>\n

Date of Birth: _______________________<\/p>\n

Race\/Nationality: ____________________<\/p>\n

Religion: ___________________________<\/p>\n

Social Security Number: __________________<\/p>\n

Address: _______________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________<\/p>\n

Length of Time at that Address: _______ years Previous Address(es) (for last 10 years): ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________<\/p>\n

Home Telephone Number: ____________________<\/p>\n

Work Telephone Number: ____________________<\/p>\n

Facsimile Number: _______________________<\/p>\n

E-mail Address: _________________________<\/p>\n

Former Name(s): ____________________ ____________________<\/p>\n

Marital Status: __________________________<\/p>\n

Previous Marriage(s): Yes ____ No ____ Ended By?______________Children<\/p>\n

Name Date of Birth Living at Home?<\/p>\n

_______________ _________ _______________<\/p>\n

_______________ _________ _______________<\/p>\n

_______________ _________ _______________<\/p>\n

_______________ _________ _______________<\/p>\n

Employer at Time of Discrimination or Harassment: ______________ ____________________________________________________________<\/p>\n

Job Position\/Title at Time of Discrimination or Harassment: ________<\/p>\n

Employer\u2019s Address ________________________________________ ____________________________________________________________ ____________________________________________________________<\/p>\n

Length of Time with Employer: _______ years ________months<\/p>\n

Date of Hire: ___________________________<\/p>\n

If Terminated, Date of Termination: _____________________<\/p>\n

What was the explanation given for your termination? ____________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________<\/p>\n

Previous Employer(s) (for last 10 years) _______________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________<\/p>\n

Gross Monthly Income at Time of Termination: $________________<\/p>\n

Other Income at Time of Termination, if any: __________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________<\/p>\n

Benefits Provided by Employer: ______________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________<\/p>\n

Date(s) of Harassment or Discrimination _______________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________<\/p>\n

Description of Harassing or Discriminatory Actions Taken Against You ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________<\/p>\n

Was anyone else treated similarly? __________________<\/p>\n

If Yes, who? _____________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________<\/p>\n

Who harassed you or discriminated against you? ________________ ____________________________________________________________<\/p>\n

What is that person\u2019s job title or description? ___________________<\/p>\n

Is he or she considered to be your supervisor? _________________<\/p>\n

Was anyone else present at the time of the discriminatory or harassing act? ___________ ___________________________________________________________ ___________________________________________________________<\/p>\n

Who was your immediate supervisor at the time? _______________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________<\/p>\n

Did you report the harassment or discrimination to anyone? _______<\/p>\n

If Yes, to whom? _________________________________________ ____________________________________________________________ ____________________________________________________________<\/p>\n

What was their response? __________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________<\/p>\n

Was a written report made? ______________________<\/p>\n

If Yes, do you have a copy of it? ____________________<\/p>\n

Were you ever given an employee handbook ? ________________<\/p>\n

Do you have a copy of it? _________________________<\/p>\n

If Yes, does it contain an anti-harassment or anti-discrimination policy? ________ ___________________________________________________________<\/p>\n

Have you ever seen a copy of an anti-harassment or anti-discrimination policy in your workplace? ______________<\/p>\n

If Yes, explain: __________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________<\/p>\n

Since the harassment or discrimination, have you spoken or had any contact with the person who harassed you or discriminated against you? __________________<\/p>\n

If Yes, explain: __________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________<\/p>\n

Have you ever been disciplined by your employer, for any reason? __________________<\/p>\n

If Yes, explain: __________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________<\/p>\n

Have you ever been harassed or discriminated against in other employment? __________<\/p>\n

If Yes, explain: __________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________<\/p>\n

Was a lawsuit filed? ______________<\/p>\n

If Yes, what was the outcome? _____________________________<\/p>\n

_______________________________________________________ ___________________________________________________________ ___________________________________________________________<\/p>\n

If you were terminated or left your employment, have you found a new job? __________<\/p>\n

Name of Present Employer _______________________________<\/p>\n

Address of Present Employer _____________________________<\/p>\n

_____________________________________________________<\/p>\n

Current Immediate Supervisor ____________________________<\/p>\n

_____________________________________________________<\/p>\n

Current Job Position\/Title ________________________________<\/p>\n

_____________________________________________________<\/p>\n

Current Gross Monthly Income ___________________________<\/p>\n

Benefits Provided by Current Employer _____________________<\/p>\n

_____________________________________________________<\/p>\n

_____________________________________________________<\/p>\n

_____________________________________________________<\/p>\n

Have you ever been arrested? ______________________<\/p>\n

If Yes, explain:________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________<\/p>\n

Are You in Good Health? ____________________________<\/p>\n

Explain all current and chronic illnesses, past and future surgeries, medications you are currently taking, and other relevant health information: ___________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________<\/p>\n

Have you ever been told that you have a physical or mental disability? _______________<\/p>\n

If Yes, explain: _______________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________<\/p>\n

Do you have a history of alcohol or drug abuse? ____________<\/p>\n

If Yes, explain: _______________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________<\/p>\n

Other Important Information ____________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________<\/p>\n

Questions to Ask My Attorney ___________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________<\/p>\n

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