LAW OFFICES OF RICHARD E.

YASKIN
1040 Kings Highway N., Suite 302
Cherry Hill, NJ 08034
(856) 667-7570 FAX: (856) 667-7573
ryaskin@njemploymentrights.com www.njemploymentrights.com

CONFIDENTIAL INTAKE FORM

ATTORNEY/CLIENT PRIVILEGE PROTECTS THIS DOCUMENT

PLEASE PRINT

Date: ________________ Age: _________

1. Name: _______________________________________________________________________________
2. Address: _____________________________________________________________________________
_____________________________________________________________________________________

3. Home Phone: __________________; Work Phone: _________________________; Cell: _____________

E-mail: _______________________

4. Are you a Veteran? _____________________

5. How were you referred to this office? ____________________________________________________

6. What happened to you?

YES NO
(a) Terminated (fired)?

(b) Suspended?

(c) Not promoted?

(d) Demoted?

(e) Harassed?

(f) Other? Describe:

7. Briefly, why do you think what happened to you was wrong?

_______________________________________________________________________________________________

8. On what date did you first learn that you would be subjected to this adverse action? Be exact! ___________

9. Employer’s identity (include name of parent corporation if your employer was a subsidiary):
_______________________________________________________________________________________________

10. Please provide the address of your work location:

Street: _________________________________________________________________________________
 City, State and Zip Code: __________________________________________________________________
11. Who advised you of the adverse personnel action?

Name: __________________________________ When: ____________________________

Title: ___________________________________

Was the notification oral or written? _______________________________________________________

12. Who was your supervisor at the time?

Name: __________________________________
Title: ___________________________________

13. What reason did the employer give: ________________________________________________________

14. What do you think is the real reason? Explain why you believe this.
_____________________________________________________________________________________________
_____________________________________________________________________________________________

15. What were your job title, salary and duties at the time of adverse action?
_____________________________________________________________________________________________
_____________________________________________________________________________________________

16. When were you hired? _________________________________________________________________________

17. Have you been presented with or have you signed a Separation Agreement and/or General Release? ______

(a) If so, what is your deadline to respond to the proposed Separation Agreement?
____________________________________________________________________________________________

(b) Please provide a copy of the Separation Agreement and any covering letter.
Retain the originals for your files.

18. Have you applied for unemployment compensation benefits?

19. What do you hope to accomplish by consulting with an employment attorney?

______________________________________________________________________________________________
______________________________________________________________________________________________

20. Are you aware of any illegal activities that occur at your workplace? _________________________________
______________________________________________________________________________________________

Signature: __________________________________________ Date: ___________________________

Return Completed Form via e-mail, fax or regular mail

PLEASE INCLUDE COPIES OF ANY IMPORTANT DOCUMENTS
DO NOT FORWARD YOUR ORIGINALS