Fortune Legal

CONFIDENTIAL CLIENT INTAKE FORM: EMPLOYMENT CASES

Thank you for considering us for your legal needs. If you are seeking legal advice about your employment situation, please complete and return the following intake form. Our office will contact you within one business day. Forms submitted online are protected via a secured link.

If your case concerns either an employment contract or a non-compete agreement, please attach a copy of that document to this intake form, using the following box.

Return to Fortune Law Offices' website ►

Attach Employment Contract or Non-Compete Agreement Here:

PERSONAL INFORMATION

Date You Are Completing This Intake Form +

First Name *

Middle Name

Last Name *

Street Address *

City *

State *

Zip Code *

Home Phone *

Cell Phone *

Personal Email Address (Please do NOT list a work e-mail address) *

Date of Birth * +

Please provide the following information, which we request only because these personal characteristics may be important to your claims:

	Please Provide Information for each line item
Gender	Please Provide Information for each line item
Race/Ethnicity	Please Provide Information for each line item
Country of Birth	Please Provide Information for each line item
Religion	Please Provide Information for each line item
Disabilities, if any	Please Provide Information for each line item

High School Attended

Year Graduated

College

Year Graduated

Degree

THE EMPLOYER OR COMPANY THAT PROMPTS YOUR LEGAL INQUIRY

Company Name *

Street Address Where You Work *

City *

State *

Zip *

How many employees does the company have in all locations total? (give your best estimate) *

ABOUT YOUR JOB

Are you a current employee?

Yes

No

If you are no longer an employee, why did your employment end? (Check all that apply)

Quit or Resigned

Forced to Quit

Fired or Laid Off

Date of Occurrence +

If you no longer work there, have you been replaced?

Yes

No

I don't know

Replacement’s Name

Age

Gender

Date Replaced +

Race

National Origin

Religion

Have you signed anything with the employer about this?

Yes

No

How long did you work for the company and its predecessor(s)

Did you have an employment contract? 🛈

Yes

No

Are or were you a member of a union?

Yes

No

Union

What is or was your job title?

Did you receive written performance appraisals?

Yes

No

How were you rated overall on your last performance appraisal?

What has been your usual or typical overall evaluation with this employer?

Do you agree with your performance appraisals in most cases?

Yes

No

Have you ever been disciplined at work?

Yes

No

Have you ever been suspended for misconduct or because you were accused of misconduct?

Yes

No

What compensation and benefits do you or did you receive? (fill in all that apply)

Base Salary per year

or Base Salary per Hour

What is your usual annual bonus?

Did you receive the following benefits?

	Yes	No
Company Stock or Stock Options	Yes	No
Health/Dental Insurance	Yes	No
Flex Savings Accounts	Yes	No
Vacation	Yes	No
Sick Leave/Personal Days	Yes	No
Pension/401 (K) Matching	Yes	No
Company Car	Yes	No

Other

ABOUT YOUR SITUATION

What services do you presently think you need? (please check one) *

Office Consultation and Advice Only

Office Consultation and ongoing representation and/or litigation

Other Other

Check any that apply to your situation

You seek advice concerning *

Proposed severance agreement

Employment Contract

Non-compete Agreement

Other (please limit explanation to 255 characters) Other (please limit explanation to 255 characters)

What reason (s) has the company given for its actions? (list all the reasons you've been given)

Are these reasons true? Explain:

List the person (s) you believe may be responsible for your employment difficulties. Guess if necessary.

Name

Job Title

Race

Date Hired +

National Origin

Age

Religion

Sex

Name

Job Title

Race

Date Hired +

National Origin

Age

Religion

Sex

ABOUT YOUR POTENTIAL CLAIMS

What type of claim (s) do you think might apply to your situation? Please check all that apply.

DISCRIMINATION CLAIMS

Yes

No

If you selected YES, please supply the following information that applies to your claim

Age (specify your age)

Disability or health issues (please specify)

Race (specify)

Gender (specify)

Pregnancy (specify date pregnancy commenced) +

National Origin (specify)

Religion (specify)

Other (specify)

HARASSMENT CLAIMS

Yes

No

Check all that apply to your Harassment Claim

Has the harassment been verbal, physical, or both?

Who has harassed you?

Name

Job Title

Date you complained +

To Whom

RETALIATION CLAIMS

Yes

No

Check all that apply to your Retaliation Claim

Retaliation for complaining of or opposing discrimination

Retaliation for complaining of or resisting harassment

Retaliation because of workers' comp claim or work injury

Retaliation for opposing illegal employer practices

Other (specify) Other (specify)

OTHER CLAIMS

Yes

No

Please check any that apply to your claim of OTHER

FMLA (Family and Medical Leave Act) (examples might include denying you FMLA leave or doing something to interfere with your job before or after you took it)

Discrimination because you have used employer provided benefits, or were likely to receive them in the future, such as health insurance, pension, short term disability or long term disability, or because you have been diagnosed with a serious illness

Breach of Contract

Unpaid Wages

Overtime Violations

Other (specify) Other (specify)

Briefly describe the facts or circumstances that cause you to believe you have the types of claims listed on the previous question (s)

Has anyone at work made any remarks that you believe were, or may be, discriminatory?

Yes

No

If yes, please describe what was said

Who said it?

Name

Title

When was it said? +

Who else may have heard the remark?

OTHER THINGS THAT MAY AFFECT YOUR CLAIMS

Have you been offered a severance package?

Yes

No

If yes, please provide the date offered +

Are you planning on accepting it?

Yes

No

Unsure

How much have you been offered?

What is the deadline to make a decision on it, if any? +

Have you filed an EEOC charge?

Yes

No

Are you aware of any deadlines affecting your claims or situation?

Yes

No

If so, what are the deadlines?

Have you signed a release of your claims?

Yes

No

If yes, date signed +

Did you sign an arbitration agreement or other agreement waiving your right to a trial?

Yes

No

Unsure

If yes, date signed +

INFORMATION ABOUT YOUR POTENTIAL DAMAGES

Please provide the best estimate, if applicable, of the total dollar amount you believe you lost because of the employer's actions and describe how you computed that figure

Have the employer's actions caused you physical or emotional distress?

Yes

No

If yes, please describe your symptoms

Have you sought or received medical or psychological treatment or counseling for these symptoms?

Yes

No

If you were fired, laid off, or otherwise forced to quit, do you want your job back?

Yes

No

If so, why?

If you were fired or laid off, please answer the following:

Have you applied for unemployment compensation?

Yes

No

If so, are you receiving benefits?

Yes

No

Have you been offered any other jobs or interviews?

Yes

No

Have you accepted any jobs?

Yes

No

If so, when were you hired? +

MISCELLANEOUS

Have you met or spoken with other attorneys concerning your employment situation?

Yes

No

If so, whom did you consult?

When? +

Are you currently represented by an attorney?

Yes

No

If so, who?

Have you ever testified in court or in a deposition before?

Yes

No

Have you ever filed a lawsuit before or been sued before?

Yes

No

Have you ever been convicted of a crime? (DO NOT LEAVE THIS SECTION BLANK. A false or misleading answer to this question is grounds for terminating the attorney-client relationship)

Yes

No

Have you ever:

	Yes	No
Filed Bankruptcy	Yes	No
Applied for disability benefits	Yes	No
Applied for Social Security	Yes	No

Please provide dates for any of the above answers

How did you find out about us?

*If you found out about us from a former client, please provide their name

**If you were referred to us by another attorney, please provide their name

What do you hope an attorney can do in your situation?

Obtain Money

Get your job back

Other

If you selected other, please provide details:

If you selected Obtain Money, what is the MINIMUM you believe it would take for you to be satisfied with the outcome, and why?

REGARDING THE ATTORNEY-CLIENT RELATIONSHIP

Submission of this form does not create an attorney-client relationship or guarantee that we can or will represent you, but it allows us to consider your request for assistance. We will keep this information CONFIDENTIAL even if we do not ultimately take your case. Once completed, please return the form to us in one of the following ways:

(1) By submitting it immediately online to Fortune Law Offices (preferred);
(2) By fax to 904.246.1551 (if you fax, please notify our office at 904.246.2125); or
(3) By mail or hand delivery to 814 1st St. N., Suite 100, Jacksonville Beach, FL 32250
.

All Intake Forms and all inquiries to this office are reviewed personally by me. If I do not agree to meet with you after reviewing your intake form, it is because I do not believe I can assist you. If we do have an office conference, however, that fact alone does not necessarily mean that I will agree to represent you, as that decision can only be made after meeting you and hearing all the relevant facts of your case. If we meet, I will give you my opinion of the merits of your case, and explain the laws that may be involved in any violations. Thank you for asking my firm to be of assistance to you.

Scott Thomas Fortune