Client Intake Questionnaire (Employment - Plaintiff)

1. Client Information

• Full legal name:
• Preferred name/pronouns:
• Date of birth:
• Residential address:
• Phone/email:
• Preferred communication method (phone/email/portal/text): Text messaging may not be confidential.

2. Employer Information

• Employer name and address:
• Supervisor/HR contact:
• Job title and department:
• Employment start date:
• Employment end date (if terminated):
• Pay rate and schedule:

3. Nature of Claims

Select all that apply:
☐ Discrimination (race/sex/age/disability/religion/national origin)
☐ Harassment / hostile work environment
☐ Retaliation
☐ Wage and hour violations
☐ Wrongful termination
☐ Whistleblower
☐ FMLA/leave violations
☐ Other: ________________________

4. Facts and Timeline

• Key events and dates:
• Complaints made to employer (who/when/how):
• Employer responses or investigations:
• Adverse actions (discipline, demotion, termination):

5. Documentation and Evidence

• Emails, texts, or memos:
• Performance reviews:
• Employee handbook/policies:
• Pay stubs/time records:
• Witnesses (names/contact info):

6. Administrative Filings

• EEOC or state agency charge filed? ☐ Yes ☐ No
• If yes, date filed and charge number:
• Right-to-sue letter received? ☐ Yes ☐ No

7. Damages

• Lost wages or benefits:
• Emotional distress or medical treatment:
• Reinstatement desired? ☐ Yes ☐ No
• Other damages sought:

8. Documents to Provide

☐ Offer letter / employment contract
☐ Employee handbook/policies
☐ Pay stubs / time records
☐ Performance evaluations
☐ EEOC charge / right-to-sue letter
☐ Emails/texts/records
☐ Other supporting documents: ________________________

9. Acknowledgment

• I certify that the information provided is accurate to the best of my knowledge and understand that submission does not create an attorney-client relationship until a written engagement agreement is signed.

Client signature: ____________________________ Date: __________

Intake received by (staff): ____________________ Date: __________