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Detailed Intake Form

Date

Name of Attorneys in Consult

Thomas E. Strelka

L. Leigh Rhoads

Full Legal Name(Required)

Prefix First Middle Last

Referral Information

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Number

Mobile Number

NEW Email Address for SEL USE

Date of Birth

Race/Ethnicity

Current Employer

Employer at Issue

If different than current employer. Public or private:

Worksite Location

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of Employees

Date of Hire

Background Check Requirement

Negative outcome:

Notification:

Title

At time of hire:

Most recent:

Rate of Pay

At time of hire:

Most recent:

Benefits? (e.g., life ins., health, retirement, vision, dental, std, ltd?)

Hours of Work Per Week

Exempt/Non-Exempt (overtime paid)

Exempt?

Description of job duties:

Supervisory capacity (executive exemption):

Decision-making capacity (administrative exemption):

Advanced/specialized education (professional exemption):

Independent Contractor

Instructions given by business:

Training provided by business:

Financial control exercised by business:

Nature of contract:

Schedule of performance:

Termination

Date of Termination

Method of termination:

Reason for Termination Provided by employer:

Reason for Termination Believed by client:

Direct Supervisor Information

Name

First Last

Title

Email(Required)

Important to get email address for filing OCR!

One Up and title

Name(s) & Title(s) of Peers/Co-workers

VEC Filing Status

Company union:

Agency fee payer:

Internal Grievance

Procedure:

Status:

Performance Reviews

Frequency:

Most Recent / How Was it?:

Performance Improvement Plan:

Disciplinary Action

Procedure:

Status:

Disability/Out-of-Work

Accommodation(s) needed/requested/provided:

Short- or long-term disability benefits:

Description of injury/illness:

Date on which client went out for illness/injury:

Date on which employee returned to work, or would have could return based on doctor’s advice:

Paid/unpaid/FMLA leave:

Health Care Providers

Have you visited any HCP or counselor due to any of the issues you experienced at work?

Harassment

Basis of harassment:

Date(s) of incidents:

Date(s) of complaints:

Discrimination

Basis of discrimination:

Date(s) of incidents:

Date(s) of complaints:

Ever been involved in litigation in the past?

Client Summary of issues

Detailed Intake Form

Background Check Requirement

Title

Rate of Pay

Exempt/Non-Exempt (overtime paid)

Independent Contractor

Termination

Direct Supervisor Information

Internal Grievance

Performance Reviews

Disciplinary Action

Disability/Out-of-Work

Health Care Providers

Harassment

Discrimination

Practice Areas

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