Mizrahi Law Intake Form

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

CONTACT INFORMATION

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

SELF-IDENTIFICATION (OPTIONAL)

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

EMPLOYER INFORMATION

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

UNLAWFUL CONDUCT ALLEGED

32. Please check the types of unlawful conduct taken against you

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 harassmentOther
If you checked “Other,” please describe

33. Please check each characteristic below that you believe is the basis for unlawful conduct against you

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 ConflictsOther
If you checked “Other,” please describe

34. If you were a whistleblower, please describe the unsafe practices and/or illegal conduct you complained about
35. Please describe the person(s) who engaged in this unlawful conduct
36. Please describe in detail with supporting facts why you believe that you have been treated wrongfully by your employer. Describe with specificity any incidents of discrimination/harassment/retaliation you suffered, including dates, times, witnesses to the conduct, and any other relevant information. Include any examples of discriminatory or offensive statements, situations where people were treated more favorably than you, and any other evidence that your employer had bias against you.
37. Over what date range did this wrongful conduct occur?
38. If the person who discriminated against you made negative comments about your race/sex/disability/other protected category, what was the frequency of the comments?DailySeveral times a weekWeeklySeveral times a monthMonthlySeveral times totalOnce
39. Describe as accurately as possible what was said to/about you that you believe is discriminatory

EMPLOYMENT HISTORY

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

EMPLOYMENT STATUS

65. Do you still work for this employer? YesNo
66. If terminated/laid off, date notified
67. If terminated/laid off, effective date of termination
68. If terminated/laid off, the person(s) who made termination decision
69. If terminated/laid off, were others terminated or laid off at the same time? If so, how many?
70. If terminated/laid off, reason(s) given for your termination/layoff
71. If terminated/laid off, what are the actual reason(s) you believe you were terminated?
72. 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.
73. If you resigned, date you gave notice
74. If you resigned, effective resignation date
75. If you resigned, was the resignation voluntary? Please explain.
76. Were you offered a severance package? YesNo
    If so, please describe amount offered
77. If applicable, do you know who replaced you? YesNo
    If so, who (name, position, and how they compare to you)?
78. Have you been searching for a job? YesNo
    If yes, describe your job search efforts
79. Have you found another job? YesNo
    If yes, start date
    If yes, compensation
80. Comments

REPORTING OF INCIDENT(S)

81. Did you report or complain about the unlawful conduct to anyone in management? YesNo
82. If so, please state the date(s) that you complained, the name(s) and title(s) of the persons to whom you complained, and what if anything was done by your employer in response
83. What were the results of the complaint/report, if any (i.e., investigation, discipline of harasser, etc.)?
84. Are you a member of a union? YesNo
    If so, have you filed any grievance with your union? YesNo
    If you filed a grievance, what was the result?

WITNESSES AND EVIDENCE

85. List the names, addresses, phone numbers, and relationship to you of any people that witnessed any unlawful conduct along with a brief description of what they witnessed
86. List the names of any other employees whom you believe were also treated unfairly, and describe how
87. Describe any documents that support your claims
88. Describe any other information that supports your claims

FINANCIAL AND EMOTIONAL HARM

89. Describe the financial impact that your employer’s wrongful conduct has had on you, including the types and amounts of income lost and the effects on you
90. Describe the effect that your employer’s wrongful conduct has had on you emotionally, psychologically, socially, and physically
91. Have ever you sought treatment from a doctor, psychologist, therapist, or other healthcare provider for depression or any other mental or psychological condition?YesNo
    If so, please describe the type of treatment received, the dates of treatment, and the name(s) of the treater(s).
92. Did you have any mental health conditions (including depression or anxiety) or pre-existing emotional problems before your employer acted unlawfully toward you? YesNo
    If yes, describe
93. Do you currently use drugs or alcohol to excess? YesNo
    If yes, please explain
94. Since your termination, have you looked for other employment? YesNo
95. Please describe any efforts you have made to find other work, including dates, names of employers applied to, and responses received
96. Feel free to share any other information about the harm your employer caused you

OTHER ACTIONS

97. Have you spoken with any other attorney concerning your employment matter? YesNo
    If so, please explain
98. Have you spoken with any other person concerning your employment matter? YesNo
    If so, please explain
99. Have you filed a complaint with the EEOC? YesNo
    If so, describe when, where, and what happened
100. Have you filed a complaint with the DFEH? YesNo
     If so, describe when, where, and what happened
101. Have you filed a complaint with any other agency? YesNo
     If so, describe when, where, and what happened
102. Have you received notice of any Right to Sue? YesNo
     If so, date of Right to Sue
103. Are there any upcoming deadlines? YesNo
     If yes, what are they?
104. Have you applied for unemployment benefits?YesNo
     If so, describe when you applied and what the result has been.
105. Have you filed with any court? YesNo
     If so, which?
106. 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
107. Have you posted anything on social media regarding your employer or legal claims? YesNo
     If so, describe

PRIOR ACTIONS

108. 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
109. Have you ever sued anyone? YesNo
     If so, describe when, where, and what happened
110. Have you ever been sued?YesNo
     If so, describe when, where, and what happened
111. Have you ever filed a workers’ compensation claim for any injuries sustained at work? YesNo
     If so, describe when and how it resolved
112. Have you ever filed for bankruptcy?YesNo
     If so, provide the date
113. Have you ever been arrested? YesNo
     If so, explain and provide the date of arrest, where, and what happened
114. Have you ever been convicted of a crime? YesNo
     If so, explain and provide details
115. 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
116. Have you ever provided inaccurate information on a résumé or job application?YesNo
     If so, please explain
117. 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)
118. Have you ever been accused of theft or any other misconduct? YesNo
     If so, please explain
119. Are you currently represented by counsel/have you been represented regarding any of the above?YesNo
     If so, please identify the attorney(s)

DOCUMENTS

120. Please check all boxes reflecting documents that you or your employer possess
     Your résuméAn offer letterHire documentsArbitration agreementEmployee handbookWritten policiesJob descriptionPerformance evaluationsWrite-ups of youPay stubs/W2Complaint lettersLetters to/from HRRelevant emailsRelevant textsRelevant photosRelevant notes/memosDocuments reflecting your job-search efforts to date

OTHER

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

PLEASE READ THE FOLLOWING TERMS CAREFULLY:

• 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 are strongly encouraged to print a copy of this page before submission.
• 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.
• If you do not hear back from Mizrahi Law within three business days, please contact us by phone.

YOU MUST CHECK THE ABOVE BOX, INDICATING THAT YOU HAVE READ AND AGREE TO THE ABOVE TERMS.

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