Initial Consultation Form

Date
Name*
Address*
Street Address Address Line 2 City State ZIP Code
Home Telephone
Personal Cell*
Home Email Address*
Is this a private e-mail, i.e., not at work or accessed by others?
- Yes
- No
Date of Birth
Marital Status
Race
National Origin
Employer with which you are having difficulty*
No. of Employees*
Union?
- Yes
- No
Federal or State Funding?
- Yes
- No
Federal Contractor?
- Yes
- No
Employer Worksite Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Hire
Job Title
Rate of Pay
Brief Description of Job Duties
How are you paid (i.e. hourly/salary)?
Are you owed Overtime?
Supervisor Name and Title*
Supervisor’s:
Age
Race
- Male
- Female
Date of Incident/Termination*
1st Date of Unpaid Overtime
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
Ever Been Convicted of a Crime?
- Yes
- No
If Yes, describe
Are 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:
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

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CONSULTATION

Name*
Email*
Phone*
Message*

Contact Info

601 West Dr. Martin Luther King Jr. Boulevard, Tampa, Florida 33603

813.251.5599
813.259.9797

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About Us

Sass Law Firm’s office is located in Tampa, Florida, and serves clients in and around the Tampa Bay area, including the counties of Hillsborough, Hernando, Manatee, Pasco, Pinellas, Polk and Sarasota.

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