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Employment law client intake form

A free intake form for employment law firms that represent workers. Part 1 is the form a new client fills in: post it on your website, send it as a PDF, or hand it over in the office. Part 2 is the questions your intake staff should ask next, because a form's answers often point to something the form can't ask about.

Print this page, or save it as a PDF from your browser's print dialog. Change it to fit your firm and your state.

This is a template, not legal advice. Agency filing deadlines differ by claim and by state, and some run six months or less from the employer's action.

Part 1: The client form

About you

  • Full name: ____________________
  • Phone: ____________________ Email: ____________________
  • Best way and time to reach you: ____________________
  • Mailing address: ____________________
  • Is it safe for us to contact you at work? ☐ No ☐ Yes ☐ I no longer work there

Your job

  • Employer's name: ____________________
  • About how many people work for the employer? ☐ Fewer than 15 ☐ 15 to 100 ☐ More than 100 ☐ Not sure
  • Is the employer a government agency? ☐ No ☐ Yes ☐ Not sure
  • Your job title: ____________________
  • Date you started: ____________________
  • Your pay: ____________________
  • How you are paid: ☐ Paycheck from the employer ☐ As a contractor ☐ Not sure
  • Does a union cover your job? ☐ No ☐ Yes ☐ Not sure
  • Do you still work there? ☐ Yes ☐ No. Your last day: ____________________

What happened

  • What did your employer do? ☐ Fired me ☐ Demoted me ☐ Cut my pay or hours ☐ Disciplined me ☐ Denied leave ☐ Denied an accommodation ☐ Didn't pay wages I'm owed ☐ Harassment ☐ Something else: ____________________
  • Date it happened: ____________________
  • Who made the decision? ____________________
  • What reason did they give, if any? ____________________
  • In your own words, what happened: ____________________
  • Why do you believe it happened? ____________________

Complaints

  • Did you complain to a supervisor or human resources? ☐ No ☐ Yes. When, and what happened: ____________________
  • Have you filed a complaint or charge with a government agency, such as the EEOC, a state agency, or the Department of Labor? ☐ No ☐ Yes. Which one, and when: ____________________
  • Have you received a right-to-sue letter? ☐ No ☐ Yes. Date: ____________________

Harassment, if any

  • Who did it? ____________________
  • How often, and over what period? ____________________
  • Is it still happening? ☐ No ☐ Yes
  • Date of the most recent incident: ____________________
  • Did you report it? ☐ No ☐ Yes. To whom: ____________________

Pay and losses

  • Pay and benefits you've lost so far: ____________________
  • Have you found a new job? ☐ No ☐ Yes. Its pay: ____________________
  • Has this affected your health? ☐ No ☐ Yes. Please describe: ____________________

Papers

  • Have you been offered severance? ☐ No ☐ Yes. Date of the offer and the deadline to sign: ____________________
  • Did you sign an arbitration agreement, a non-compete, or a severance agreement? ☐ No ☐ Yes ☐ Not sure. Which: ____________________
  • Which of these do you have? ☐ Offer letter ☐ Contract ☐ Handbook ☐ Evaluations ☐ Discipline notices ☐ Termination letter ☐ Pay stubs ☐ Texts or emails
  • Have you talked with another lawyer about this? ☐ No ☐ Yes

Anything else

  • Is there anything else we should know? ____________________
  • How did you hear about us? ____________________

Sending this form does not make this firm your lawyer. The firm will contact you to talk about whether it can help.

Part 2: The questions to ask next

A form takes the answer it gets. These are the questions to ask when an answer is thin, or when it points to something the form didn't ask. Each one starts from an answer on the form.

Deadlines

  • The client names an action and a date. Get the date of each adverse action, including the last day worked. Some agency deadlines run six months or less from the employer's action.
  • The client describes harassment. Get the date of the most recent incident.
  • The client filed a charge with an agency. Get the agency, the date filed, and the date of any right-to-sue letter.
  • The client was offered severance. Get the deadline to sign, and flag it to an attorney the same day.

Why the employer acted

  • The client believes the reason was unlawful. Ask for the facts behind the belief: comments made, the timing, and how others in the same position were treated.
  • The client complained before the action. Get what they complained about, to whom, when, and what happened next. An action soon after a complaint matters.
  • The client took leave, was injured, became pregnant, or reported wrongdoing. Get the date of each, and the date of the action that followed.

The employer's side

The employer will offer a reason. Ask about it plainly now, so the attorney hears it first:

  • Performance reviews, warnings, and discipline before the action.
  • Any policy the employer says the client broke.
  • Any complaint made about the client.

The client's own part

  • Anything the client signed, said, or accepted from the employer since the action.
  • Any statement they gave, to the employer or to an agency.
  • Whether they have looked for work since.
  • Anything they took, kept, or posted about the employer.

Wages

  • The client says they weren't paid what they're owed. Ask for the hours worked, the pay received, overtime, tips, and how hours and pay were recorded.

Situations to handle with care

  • A severance agreement or release is waiting to be signed. Ask the client not to sign before an attorney reads it, and flag it the same day.
  • Harassment is ongoing, or the client feels unsafe at work. Ask whether they are safe now.
  • The client reported wrongdoing to a government agency and was punished for it. Get the agency and the dates.
  • A non-compete is blocking a new job now. Get the new job's start date.

When the matter may be another area of law

  • Hurt or made sick by the work itself: possibly a workers' compensation claim. A firing over the injury stays an employment matter.
  • A government employer that also violated constitutional rights: possibly a civil rights matter.
  • Immigration status used as a threat, or a work visa at risk: the client may also need an immigration lawyer.
  • A dispute among business owners, or between two businesses: a business matter, not an employment one.

Ask these questions without a form

Verantel asks these questions as an interview. It talks with the people who reach your firm, in plain language and in their own language, and asks the next question when an answer points to a filing deadline, a severance agreement waiting to be signed, or the reason the employer acted. Then it hands your firm a structured record, with the interview line each fact came from. Verantel is not a lawyer and gives no legal advice.

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