A Pasadena Employment Law Firm

Committed to Helping Workers


(626) 380-9000

SSL CertificateThank you for contacting us regarding your legal claims. Please fill out the form below as truthfully, accurately, and completely as possible. There will be space at the bottom for you to add any additional information you deem important. Be sure to carefully read the instructions at the end before submitting. The form is comprehensive and thorough and may take some time to fill out, so please set aside enough time to complete it. We thank you in advance for your time and efforts.

  1. Your name
  2. How did you find us? (If through an internet search, what keywords did you use?)

  4. Your email (required)
  5. Mailing address (with city, state, zip code)
  6. Cell number
  7. Home number
  8. Work number
  9. What is the best time and way to reach you?
  10. Are your phone and email safe to send confidential information? YesNo

  12. Date of birth
  13. Age
  14. Gender
  15. Marital status
  16. Sexual orientation
  17. Race & national origin
  18. Disability (if any)
  19. Religion
  20. If you have children, their ages
  21. Highest level of education attained
    Less than high schoolHigh school graduate or GEDSome collegeBachelor's degreePostgraduate degree
  22. Feel free to share any other self-identification or category relevant to your claims

  24. Name of employer that you have legal claims against
  25. Employer address
  26. Location where you worked
  27. Names of parent/subsidiary/related corporations
  28. Employer’s type of business
  29. Number of employees
  30. Name of company on paycheck
  31. Name and position of supervisor

  33. Date of hire
  34. Last position title
  35. Did you receive any promotions? YesNo
  36. Any demotions? YesNo
  37. Salary/Pay (yearly)
  38. Bonus/commissions (if any)
  39. Did you receive medical insurance? YesNo
  40. Dental? YesNo
  41. 401(k) matching? YesNo
  42. Pension? YesNo
  43. Other benefits?YesNo
    If yes, please describe:
  44. Did you have a written employment contract? YesNoI don't know
  45. Did you sign an arbitration agreement? YesNoI don't know
  46. How would you rate your performance?
  47. Did you receive performance reviews? YesNo
    If yes, date of most recent review
    What was the rating you received on your most recent review? (Please specify scale.)
  48. Were you even on probation? YesNo
  49. Did you ever receive any discipline or poor evaluation? YesNo
    If so, did you ever object to it?YesNo
  50. Please describe any discipline or poor evaluation, including when it was received, what it was for, and whether you agreed with it
  51. Describe your job duties
  52. Did you work over 40 hours per week? NeverRarelySometimesOftenRegularly
  53. Were you eligible for overtime hours? YesNoI don't know
  54. Did you receive overtime for working more than 8 hours per day or 40 hours per week? YesNoI don't know
  55. If paid hourly, did you ever work off the clock? YesNoI don't know
  56. Did you regularly skip lunch breaks? YesNoI don't know

  58. Do you still work for this employer? YesNo
  59. If terminated/laid off, date notified
  60. If terminated/laid off, effective date of termination
  61. If terminated/laid off, the person(s) who made termination decision
  62. If terminated/laid off, were others terminated or laid off at the same time? If so, how many?
  63. If terminated/laid off, reason(s) given for your termination/layoff
  64. If terminated/laid off, what are the actual reason(s) you believe you were terminated?
  65. If you were laid off in a reduction in force, please list the people in comparable positions to yours who were laid off and those who were retained. Please explain why you believe that one or more of the persons who were retained should have been laid off instead of you.
  66. Were you offered a severance package? YesNo
    If so, please describe amount offered
  67. If applicable, do you know who replaced you? YesNo
    If so, who (name, position, and how they compare to you)?

  69. Please check the types of any unlawful conduct that you believe was taken against you
  70. TerminatedLaid offDemotedForced to QuitHarassedDenied employmentDenied promotionDenied TransferDenied accommodation for disabilityDenied medical leaveDenied family leaveDenied pregnancy leaveDenied accommodations for pregnancyDenied accommodations for breastfeedingSubjected to negative comments about your protected characteristics by a supervisor/co-worker(s)Subjected to physical threatsSubjected to sexual harassmentOtherNone
    If you checked “Other,” please describe

  71. Please check each characteristic below that you believe was the basis for any unlawful conduct against you
  72. Your sex/genderYour ageYour raceYour national originYour religionYour sexual orientation (actual or perceived)Your pregnancyYour marital statusYour need to care for someone who is illYou are disabledYou are perceived as disabledYour association with someone in a protected categoryYou complained about harassment or discrimination against you or othersYou were a whistleblower who complained about unsafe practices or illegal conductPersonality ConflictsOtherNone
    If you checked “Other,” please describe


  73. Have you spoken with any other attorney concerning your employment matter? YesNo
    If so, please explain
  74. Have you spoken with any other person concerning your employment matter? YesNo
    If so, please explain
  75. Have you filed a complaint with the EEOC? YesNo
    If so, describe when, where, and what happened
  76. Have you filed a complaint with the DFEH? YesNo
    If so, describe when, where, and what happened
  77. Have you filed a complaint with any other agency? YesNo
    If so, describe when, where, and what happened
  78. Have you received notice of any Right to Sue? YesNo
    If so, date of Right to Sue
  79. Are there any upcoming deadlines? YesNo
    If yes, what are they?
  80. Have you applied for unemployment benefits?YesNo
    If so, describe when you applied, reason stated for termination, and what the result has been.
  81. Have you filed with any court? YesNo
    If so, which?
  82. Do you have a social media page or website? YesNo
    If so, are they publicly viewable? YesNo
    Please provide the URLs to your Facebook, LinkedIn, and Twitter Pages
  83. Have you posted anything on social media regarding your employer or legal claims? YesNo
    If so, describe

  85. Have you ever complained about harassment, discrimination, or wrongful treatment (other than the complaints you may have described above) to your employer or to a government agency? YesNo
    If so, please describe in detail the complaints made and how they were resolved
  86. Have you ever sued anyone? YesNo
    If so, describe when, where, and what happened
  87. Have you ever been sued?YesNo
    If so, describe when, where, and what happened
  88. Have you ever filed a workers’ compensation claim for any injuries sustained at work? YesNo
    If so, describe when and how it resolved
  89. Have you ever filed for bankruptcy?YesNo
    If so, provide the date
  90. Have you ever been arrested? YesNo
    If so, explain and provide the date of arrest, where, and what happened
  91. Have you ever been convicted of a crime? YesNo
    If so, explain and provide details
  92. Have you ever been terminated or asked to resign from any other job? YesNo
    If so, please describe the circumstances and the reasons given to you
  93. Have you ever provided inaccurate information on a résumé or job application?YesNo
    If so, please explain
  94. Is there anything that you stated on your application for the job from which you were fired false, inaccurate, or misleading (including by omission)? YesNo
    If so, please explain (it is critical that you be truthful)
  95. Have you ever been accused of theft or any other misconduct? YesNo
    If so, please explain
  96. Are you currently represented by counsel/have you been represented regarding any of the above?YesNo
    If so, please identify the attorney(s)
  97. OTHER

  98. Is there anything else we should know about your case?
  99. Is there anything else that we ought to know about you, your employer, your history, or any other topic?


  • This form is solely for the use of Mizrahi Law for the purposes of evaluating your potential claims. The contents of this form are therefore protected by the attorney-client privilege and attorney work product doctrine.
  • However, submitting information via this form does not create an attorney-client relationship.
  • Mizrahi Law will not represent any person unless we have explicitly agreed to do so through a written retainer agreement.
  • Do not submit this form from a company computer or device.
  • Do not submit any confidential, proprietary, or sensitive information via this form.
  • It is important that you be truthful, accurate, and complete in answering all questions. Because your employer will likely seek to obtain all relevant records and information, it is crucial that we be made aware of all relevant information, even that which may be harmful to your case.
  • Please also keep in mind that legal claims are subject to a statute of limitations (a time period within which they must be brought or be forfeited). Please do not use this form to request contact regarding any time-sensitive matter.
  • Mizrahi Law’s practice is focused on claims of: (1) harassment, discrimination, and unlawful treatment of workers based on sex, race, disability, pregnancy, age, sexual orientation, religion, national origin, or need for family or medical leave; (2) denial of reasonable accommodations for disabilities; (3) denial of pregnancy, disability, or family leave; (4) retaliation for opposing any of the above discrimination and harassment; and (5) termination for refusing to engage in illegal activity, or for protesting reporting, or complaining about illegal activity. If we decline to take your case, this does not mean that you do not have a case, and you should consult with other attorneys immediately.
  • You will receive a confirmation email if the form is submitted. If you do not receive a confirmation email, this means that there was an error with your submission.
  • You are strongly encouraged to print a copy of this page before submission.
  • If you do not hear back from Mizrahi Law within three business days, please contact us by phone.


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