Tell Us About Your Claim Telfer Law Employment Law Intake Form Intake Form for Employment Law cases Step 1 of 5 20% Name* First Last Phone*Alternative PhoneEmail* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date of Birth* Are you married?YesNoSpouse Name First Last Spouse PhoneHow did you hear about our office?Do you have any hearings or appearances that require attendance?YesNoDate* Time : HH MM AM PM What is the purpose of the hearing?Are there any important circumstances that you think require immediate attention?*YesNoPlease explain:Current employment status:*EmployedUnemployedSelf-EmployedDate Employment Terminated* Date of Last Discipline/Adverse Action* Were you:* Discriminated against Retaliated against Harassed What do you believe this was based on:* Age Gender Sex Race Marital Status Disability Complaint of treatment Medical Leave Other Explain: Name of Defendant / Employer*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Approximate number of employees:Location of Headquarters:Name of Company on PaycheckPotential Individual Defendants:NamePosition Did the company use progressive discipline?*YesNo(Counseling and verbal warning; Written warning; Suspension and final written warning; Recommendation for termination of employment)Did you have a written contract for your employment?YesNoDid the company have written personnel policies or an Employee Handbook*YesNoI don't knowDid you sign an Arbitration Agreement?*YesNoSection BreakDate Hired* MM DD YYYY Salary at hire:*Position at hire:Were you ever promoted?*Yes, onceYes, more than onceNoWere you ever demoted?*Yes, onceYes, more than onceNoHave you been written up for any reason?YesNoPlease Explain:*Have you been disciplined by your employer?YesNoPlease Explain:*Current position*Current salary:*Have you suffered an adverse employment action such as termination, demotion, failure to promote, suspension, reduction in hours or pay, or other?*YesNo Was your employment terminated?*YesNoDate Notified of Termination* MM DD YYYY Last Date Worked* MM DD YYYY Position at time of termination*Did you file for Unemployment Benefits?*YesNoWhat was the ultimate outcome?*Were you presented a severance agreement? If so, when?*Date notified of last adverse action?* Date effective:* Describe the Adverse Action*Reason given for the adverse action(s):*What do you believe the true reason is?*(Such as being in a protected class based on race, sex, national origin, age, disability, religion, sexual orientation or engaging in protected activity such as whistle-blowing, using medical leave or filing a worker’s compensation claim)If you believe you have been subjected to sexual harassment or subjected to a hostile work environment based upon your being part of a protected class (such as sex, race, age, religion, disability, sexual orientation or national origin), please describe in detail the conduct to which you have been subjected, including any relevant dates.*Did someone replace you?*YesNoWho replaced you?Have you complained about your treatment?*YesNoTo Who?*Check all that apply My Supervisor My Co-workers Human Resources Internal EEO Office Other Explain:Have you filed any complaint with any of the following agencies?* DFEH - Department of Fair Employment and Housing EEOC - Equal Employment Opportunity Commission Civil Rights Office Other None Explain:Have you been issued a Right to Sue?*YesNoHave you previously spoken with an attorney concerning your employment matter?*YesNoDid you sign a Fee Agreement?*YesNoWere other employees treated differently and/or better than you were treated? Who? How?*Other facts suggesting discrimination/retaliation (e.g., discriminatory remarks, admissions) or unfair treatment:*Are there witnesses who have information regarding your claims?*YesNoWitness(es) Name and Contact Information*Are the witnesses willing to speak with our firm?*Have you given a written or verbal statement to anyone regarding the circumstances of your employment or claims?*YesNoHave you ever been involuntarily terminated from any previous employer?*YesNoPlease explain:* Are you currently seeking medical (physical and/or mental health) treatment as a result of your employment?*YesNoPlease explain:*Have you previously sought medical treatment for any reason related to your employment?*YesNoPlease explain:*Did you inform your employer?*YesNoWhat is the approximate amount of your medical bills, if known? Do you currently have another attorney representing you in this matter?*YesNoWho?*Have you ever been a party to a litigation?*YesNoPlease explain:*How did you learn of the Law Offices of Jill P. Telfer?*Do you have any social media accounts, including any Facebook, Instagram, Twitter, or other related account?*Please list each email account you maintain: Have you ever been charged with a misdemeanor or a felony?*YesNoPlease explain:*Have you or are you filing for bankruptcy?*YesNoPlease explain:*Please provide any and all relevant documents to your case: Drop files here or Please provide any other information that you think we need to evaluate your case:I understand that this is a free consultation about my employment matter and that I am not represented until I speak with the attorney who agrees to accept my case and I sign a fee agreement. I understand that my case may or may not be accepted by the attorney.*YesNo
