Terminated Employee Intake Form

Please fill out the Intake Form below. If we can take your case, we will contact you. Please understand that we cannot take every case, and we select cases based on a number of factors, only one of which is our view of the strength of the claim.

Intake Form

Please take a moment to fill out the form. Please note that only forms that are filled out completely can be reviewed. Please remember that submitting this form does not mean that the Firm will take your case or that the Firm represents you. The Firm will only represent you once a retainer agreement is signed both by you and a member of the Firm.

First Name

Last Name

Personal Email

Employer Name and Location

Start and End Date of Employment

Salary/Compensation

Reason You Believe You Were Fired

Do you believe your termination was related to any of the follwing? (Check all that apply.) * Required

Race or ethnicity

Sex or gender

Pregnancy

Age

Disability or medical condition

Religion

Sexual orientation

National Origin

Reporting illegal practices

Not sure

None of the above

If you complained about or reported illegal activity, who did you report it to and when?

Did anyone at work ever make any discriminatory statments toward you, such as about your race, age, gender, sexual orientation, national origin, etc.? If so, what did he/she say?

Did you recieve any discipline or were you ever put on a performance improvement plan when you were employed with this employer? If so, when and for what?

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2525 Ponce De Leon Blvd., Suite 300

Coral Gables, FL 33134

48 Wall St., Suite 1100

New York, NY 10005

*by appointment only

Tel: 305-677-8713

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