Intake Form

NAME:
PHONE:
EMAIL:
ADDRESS:
DATE OF BIRTH:

WHAT IS THE BEST WAY TO CONTACT YOU?

NAME AND ADDRESS OF EMPLOYER AT ISSUE:

HOW MANY EMPLOYEES OF EMPLOYER AT ISSUE?

DATE OF EMPLOYMENT WITH EMPLOYER AT ISSUE:

A. START DATE:

B. END DATE:

HAVE YOU FILED AN EEOC CHARGE?

HAVE YOU RECEIVED A RIGHT TO SUE NOTICE FROM THE EEOC?

LAST SALARY WITH EMPLOYER AT ISSUE:

FRINGE BENEFITS:

PLEASE DETAIL ANY BENEFITS YOU RECEIVED, INCLUDING BUT NOT LIMITED TO HEALTH, VISION, DENTAL, 401K, AND/OR DEPENDENT COVERAGE:

PROMOTIONAL/DISCIPLINARY HISTORY:

A. PLEASE DESCRIBE YOUR PROMOTIONAL HISTORY WITH THE EMPLOYER:

B. PLEASE DESCRIBE YOUR DISCIPLINARY HISTORY WITH THE EMPLOYER AT ISSUE:

NATURE OF DISPUTE:

A. PLEASE DESCRIBE IN DETAIL THE CIRCUMSTANCES LEADING TO AND SURROUNDING YOUR DISPUTE:

B. IF TERMINATED/DISCIPLINED, WHAT WAS THE REASON STATES FOR THE TERMINATION/DISCIPLINE?

PRIOR OR CURRENT LAWSUITS:

HAVE YOU BEEN INVOLVED IN ANY PRIOR LAWSUITS OF ARE CURRENTLY INVOLVED IN ANY LAWSUITS (INCLUDING BANKRUPTCY FILINGS)?

IF SO, PLEASE SPECIFY THE COURT, CASE NUMBER, SUBJECT MATTER, AND FINAL DISPOSITION:

MEDICAL HISTORY:

A. PLEASE LIST ALL DIAGNOSED MEDICAL CONDITIONS THAT RELATE TO YOUR DISPUTE:

B. PLEASE LIST ALL MEDICATIONS/PRESCRIPTIONS YOU CURRENTLY TAKE THAT RELATE TO YOUR DISPUTE:

CRIMINAL:

PLEASE DETAIL ANY ARRESTS, INDICTMENTS, AND/OR CONVICTIONS

ANY OTHER RELEVANT INFORMATION:
HOW DID YO HEAR ABOUT THE COLES FIRM P.C.?