Attorney Intake Form: Facing Discrimination & Harassment At Work

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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. 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, 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.

Full Legal Name: _____________________________

Gender: ____________________________

Date of Birth: _______________________

Race/Nationality: ____________________

Religion: ___________________________

Social Security Number: __________________

Address: _______________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

Length of Time at that Address: _______ years Previous Address(es) (for last 10 years): ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

Home Telephone Number: ____________________

Work Telephone Number: ____________________

Facsimile Number: _______________________

E-mail Address: _________________________

Former Name(s): ____________________ ____________________

Marital Status: __________________________

Previous Marriage(s): Yes ____ No ____ Ended By?______________Children

Name                Date of Birth   Living at Home?

_______________ _________ _______________

_______________ _________ _______________

_______________ _________ _______________

_______________ _________ _______________

Employer at Time of Discrimination or Harassment: ______________ ____________________________________________________________

Job Position/Title at Time of Discrimination or Harassment: ________

Employer’s Address ________________________________________ ____________________________________________________________ ____________________________________________________________

Length of Time with Employer: _______ years ________months

Date of Hire: ___________________________

If Terminated, Date of Termination: _____________________

What was the explanation given for your termination? ____________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

Previous Employer(s) (for last 10 years) _______________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

Gross Monthly Income at Time of Termination: $________________

Other Income at Time of Termination, if any: __________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

Benefits Provided by Employer: ______________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

Date(s) of Harassment or Discrimination _______________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

Description of Harassing or Discriminatory Actions Taken Against You ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

Was anyone else treated similarly? __________________

If Yes, who? _____________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

Who harassed you or discriminated against you? ________________ ____________________________________________________________

What is that person’s job title or description? ___________________

Is he or she considered to be your supervisor? _________________

Was anyone else present at the time of the discriminatory or harassing act? ___________ ___________________________________________________________ ___________________________________________________________

Who was your immediate supervisor at the time? _______________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

Did you report the harassment or discrimination to anyone? _______

If Yes, to whom? _________________________________________ ____________________________________________________________ ____________________________________________________________

What was their response? __________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

Was a written report made? ______________________

If Yes, do you have a copy of it? ____________________

Were you ever given an employee handbook ? ________________

Do you have a copy of it? _________________________

If Yes, does it contain an anti-harassment or anti-discrimination policy? ________ ___________________________________________________________

Have you ever seen a copy of an anti-harassment or anti-discrimination policy in your workplace? ______________

If Yes, explain: __________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

Since the harassment or discrimination, have you spoken or had any contact with the person who harassed you or discriminated against you? __________________

If Yes, explain: __________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

Have you ever been disciplined by your employer, for any reason? __________________

If Yes, explain: __________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

Have you ever been harassed or discriminated against in other employment? __________

If Yes, explain: __________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

Was a lawsuit filed? ______________

If Yes, what was the outcome? _____________________________

_______________________________________________________ ___________________________________________________________ ___________________________________________________________

If you were terminated or left your employment, have you found a new job? __________

Name of Present Employer _______________________________

Address of Present Employer _____________________________

_____________________________________________________

Current Immediate Supervisor ____________________________

_____________________________________________________

Current Job Position/Title ________________________________

_____________________________________________________

Current Gross Monthly Income ___________________________

Benefits Provided by Current Employer _____________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

Have you ever been arrested? ______________________

If Yes, explain:________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

Are You in Good Health? ____________________________

Explain all current and chronic illnesses, past and future surgeries, medications you are currently taking, and other relevant health information: ___________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

Have you ever been told that you have a physical or mental disability? _______________

If Yes, explain: _______________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

Do you have a history of alcohol or drug abuse? ____________

If Yes, explain: _______________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

Other Important Information ____________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

Questions to Ask My Attorney ___________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

Next Steps

Contact a qualified employment attorney to make sure your rights are protected.

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