Initial Consultation Form Date DD slash MM slash YYYY Name*Salutation Mr. Ms. Mrs. Mx. Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Telephone*Personal Cell*Personal Email Address* Is this a private e-mail, i.e., not at work or accessed by others?* Yes No Date of Birth* MM slash DD slash YYYY Marital Status*Race*National Origin*Gender Identity*Employer with which you are having difficulty*Is this an education related matter?* Yes No Do you work in a public school District?What is your job title?Did you receive written charges against you? Yes No On What Date? MM slash DD slash YYYY Were you suspended, terminated, or did you receive notice that the employer/school would not renew your employment contract? Yes No What date did the suspension, termination, or notice occur? MM slash DD slash YYYY Have you filed a charge or complaint with the EEOC, FCHR or any other governmental agency?* Yes No Have you received a right to sue or decision on the merits?* Yes No What date did you receive a right to sue or a decision on the merits? MM slash DD slash YYYY Employer's No. of Employees*Does your workplace have a union?* Yes No Does your employer/institution receive federal and/or state funding?* Yes No Is your employer and/or institution a federal contractor?* Yes No Employer/Institution Worksite Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Hire* MM slash DD slash YYYY Job Title*Rate of Pay*Brief Description of Job Duties*How are you paid (i.e. hourly/salary)?*Are you owed Overtime?1st Date of Unpaid Overtime MM slash DD slash YYYY Supervisor Name and Title*Supervisor’s:Age*Race** Male Female Date of Incident/Termination* MM slash DD slash YYYY If known, name of Replacement*Replacement’s:Age*Race* Male Female Brief Description of Events Complained of*Is the nature of your issue related to COVID-19*Are you subject to an Arbitration Agreement?* Yes No Have you taken any documents from your employer, including forwarded emails from your employer’s email system to your personal email?* Yes No Ever Filed Bankruptcy?* Yes No If Yes, when MM slash DD slash YYYY Ever Been Convicted of a Crime?* Yes No If Yes, describeAre you receiving any governmental assistance, i.e. Medicare/Medicaid* Yes No Are you receiving any disability payments?* Yes No Have you filed for unemployment benefits?* Yes No Have you signed one of the following with your employer:Non-Compete Agreement* Yes No Non-Solicitation Agreement* Yes No Confidentiality Agreement* Yes No Have you spoken to another lawyer regarding this matter?* Yes No Have you retained counsel on this matter previously?* Yes No If yes to either, please indicate name and address:How did you hear about our firm?* Client Referral Attorney Referral Google search AVVO Florida Bar NELA The initial consultation is for the purpose of evaluating your claim and explaining possible remedies available. There is no guarantee that the attorneys will accept your claim for handling pre-suit, through administrative process or litigation. Should additional services be desired and agreed to, both you and the attorney will be required to sign a written Representation Agreement describing the services to be performed and the method of additional payment for those services.Signature*Please type your name
