Fortune Law Offices, P.A.
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.

 

PERSONAL INFORMATION

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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
Race/Ethnicity
Country of Birth
Religion
Disabilities, if any

THE EMPLOYER OR COMPANY THAT PROMPTS YOUR LEGAL INQUIRY

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

ABOUT YOUR JOB

Are you a current employee?
If you are no longer an employee, why did your employment end? (Check all that apply)
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If you no longer work there, have you been replaced? 
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Have you signed anything with the employer about this?
Did you have an employment contract? 
Are or were you a member of a union?
Did you receive written performance appraisals?
Do you agree with your performance appraisals in most cases? 
Have you ever been disciplined at work?
Have you ever been suspended for misconduct or because you were accused of misconduct?
Did you receive the following benefits?
 YesNo
Company Stock or Stock Options
Health/Dental Insurance
Flex Savings Accounts
Vacation
Sick Leave/Personal Days
Pension/401 (K) Matching
Company Car

ABOUT YOUR SITUATION

What services do you presently think you need?  (please check one) *
 
Check any that apply to your situation
You seek advice concerning *
 
List the person (s) you believe may be responsible for your employment difficulties.  Guess if necessary.
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ABOUT YOUR POTENTIAL CLAIMS

What type of claim (s) do you think might apply to your situation?  Please check all that apply.
DISCRIMINATION CLAIMS
If you selected YES, please supply the following information that applies to your claim
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HARASSMENT CLAIMS
Check all that apply to your Harassment Claim
 
Who has harassed you?
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RETALIATION CLAIMS
Check all that apply to your Retaliation Claim
 
OTHER CLAIMS
Please check any that apply to your claim of OTHER
 
Has anyone at work made any remarks that you believe were, or may be, discriminatory? 
Who said it?
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OTHER THINGS THAT MAY AFFECT YOUR CLAIMS

Have you been offered a severance package?
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Are you planning on accepting it?
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Have you filed an EEOC charge?
Are you aware of any deadlines affecting your claims or situation?
Have you signed a release of your claims?
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Did you sign an arbitration agreement or other agreement waiving your right to a trial?
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INFORMATION ABOUT YOUR POTENTIAL DAMAGES

Have the employer's actions caused you physical or emotional distress?
Have you sought or received medical or psychological treatment or counseling for these symptoms?
If you were fired, laid off, or otherwise forced to quit, do you want your job back?
If you were fired or laid off, please answer the following:
Have you applied for unemployment compensation?
If so, are you receiving benefits? 
Have you been offered any other jobs or interviews?
Have you accepted any jobs?
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MISCELLANEOUS

Have you met or spoken with other attorneys concerning your employment situation?
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Are you currently represented by an attorney?
Have you ever testified in court or in a deposition before?
Have you ever filed a lawsuit before or been sued before?
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)
Have you ever:
 YesNo
Filed Bankruptcy
Applied for disability benefits
Applied for Social Security
How did you find out about us?
 
What do you hope an attorney can do in your situation?

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 1807 3rd St. North, 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