CONFIDENTIAL POTENTIAL CLIENT QUESTIONNAIRE

Name *
Address *
Email *
How did you hear about us? *
Attorney Referred to
   
Date of Birth
SS No.
   
Phone  
Work
Home
Cell
Fax
   
Employer in Question
Employer's Address
Home Office
Your Position
Your Salary
Your Supervisor's Name

Length of your employment
Number of Empoyees
   
Reasons given to you for termination/demotion
Hire date
Termination date
 

Describe your work record
 
Type of claim (check all that apply)
Sexual harassment
Race Discrimination
Gender Discrimination
Age Discrimination
Disability Discrimination
Religion Discrimination
Retaliation
Breach of employment contract
Non-competition agreement
Worker's compensation retaliation
Review of Severance Agreement
Health insurance and other benefits
FMLA
Whistleblower
   
Have you filed a charge of discrimination either with the Equal Employment Opportunity Commission or the Texas Commission on Human Rights?
Yes No
If so, when?
   
Have you received a "Right to Sue" letter?
Yes No
If so, when?
   
Please use the remainder of the form to share any additional facts that you feel will allow us to help you:
   
Please attach any documents you feel will be helpful in evaluating your case.
 
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