New Client Intake Form

Name*
First Last
Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
Email Address*
Date of Birth*
MM slash DD slash YYYY
What is the best number to use to reach you and what is the best time to contact you?*
How did you learn of our firm/hear about us?*
Employer*
Employer Address
Street Address City State / Province / Region ZIP / Postal Code
Employer Phone*
Date you were hired?*
MM slash DD slash YYYY
Date you last worked for that employer?*
MM slash DD slash YYYY
Did you resign, quit, or get terminated?
- resigned
- quit
- terminated
What reason was given for your termination?*
What was your job title?*
What were your job duties?*
What was your rate of pay?*
Do you have a written contract for employment with this employer?*
- Yes
- No
Were you a member of the union while employed by this employer?*
- Yes
- No
Did you ever work more than 8 hours per day or 40 hours per week and not get paid overtime?*
- Yes
- No
Were you able to take a 10 minute break after every 4 hours of work?*
- Yes
- No
Were you permitted to take an uninterrupted, duty-free lunch or meal period of at least 30 minutes during your workday?*
- Yes
- No
Have you filed a complaint regarding your wages with the Labor Commissioner?*
- Yes
- No
If so, when?*
Do you know of other people who worked for the employer you are complaining about who were also denied their lunch/meal or rest breaks?
- Yes
- No
If so, what is their name and telephone number?
How many full time employees at the workplace?*
Was your termination voluntary?*
- Yes
- No
Do you think you were wrongfully terminated?*
- Yes
- No
Why do you believe your termination was wrongful?*
Were you a victim of any of the following while employed:*
- Sexual Harassment
- Race or National Origin Discrimination
- Gender Discrimination
- Pregnancy Discrimination
- Age Discrimination
- Disability/Medical Discrimination
- Sexual Orientation Discrimination
- Denial of Medical or Family Leave
- Unpaid Wages / Denied Breaks
- Other
If other, please expain:*
What is the name and title of the person you believe discriminated against or harassed you?*
Were there any witnesses to the treatment you are complaining about?*
- Yes
- No
Was anyone else also discriminated against or harassed based on the above?*
- Yes
- No
Did you ever complain to your employer of how you were being treated at work?*
- Yes
- No
What happened after you complained?*
What was the last date you were harassed or discriminated against?*
MM slash DD slash YYYY
Have you filed a formal complaint with the Department of Fair Employment and Housing or the EEOC regarding your claims?*
- Yes
- No
If so, when?*
MM slash DD slash YYYY
Have you received a “Right-to-Sue” letter from a governmental agency?*
- Yes
- No
During your employment did you become aware that your employer was engaging in conduct you believed was wrongful or illegal?
- Yes
- No
Did you refuse to participate in that conduct?
- Yes
- No
Did you complain to anyone about that conduct?
- Yes
- No
What happened after you complained?
Have you been able to secure a new job?*
- Yes
- No
Who is your current employer?*
What is your current rate of pay?*
What is your current job title and job duties?*
If there is any additional information that you would like to provide, please feel free to use this space to do so:
If you have any written documents or witness statements regarding your claims, please fax this fact sheet, together with those documents to (805) 845-9634. You may also email this document as an attachment to [email protected]

Thank you for contacting Adams Law regarding your legal claims or questions. We value each potential client who contacts us and will make arrangements to meet or speak with you when convenient, including Saturdays. Please be advised, however, that Adams Law is not your legal counsel until there is a signed fee agreement in place between you and the firm. By submitting this form, you are requesting that we evaluate whether you have a valid claim. We have not agreed to act as your legal counsel.

You are required to acknowledge that you understand that Adams Law is not your legal representative and has not undertaken to represent you merely by the submission of this fact sheet. Please sign and date below
Signature (Printed Name)*
First Last
Date*
MM slash DD slash YYYY

Contact Information

Santa Barbara Office
805.845.9630 phone
805.845.9634 fax

San Diego Office
858.922.5427 phone
805.845.9634 fax

Additional Contact Info »

Practice Areas

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Employee Rights Law Firm Serving the needs of California’s employees from Santa Barbara to San Diego.

Adams Employment Law

Santa Barbara Office
805.845.9630 TEL
805.845.9634 FAX

San Diego Office
858.922.5427 TEL
805.845.9634 FAX
Additional Contact Info »