Consultation Request

Employment

Thank you for your interest in the Law Offices of Debra E. Schwartz, LLC.

So that we can best determine if we can help you, please fill out the following questionnaire. You may skip those portions of the form that are not relevant to your case, but be sure to fill in the required fields, marked with an *.

THIS FORM IS COMPLETELY CONFIDENTIAL.
The information you provide to us will not be discussed with anyone but you. Please note that submitting this consultation request form does not mean you have retained us as your attorneys. We reserve the right not to take the case which you are requesting us to review.

* Date:
* Name:
* Age:
* Who Referred You to The Law Offices of Debra E. Schwartz?
Home Telephone Number:
Work Telephone Number: (If it is OK to call)
Mobile Telephone Number:
Email Address:
* Home Address:
Please check all that apply: I am not being paid earned overtime or have other pay issues I have been discriminated against I am being sexually harassed and need help I am being denied my rights under the Family and Medical Leave Act I have a severance package that needs to be reviewed I am a small employer seeking representation (STOP HERE, press submit at the bottom of the form and we will call you) I am charged with sexual harassment and need to be defended I am a public employee whistleblower
Other:

Employment Discrimination Questions
* Employer you are contacting us about:
* Hire date:
* Current or Last position held:
Brief Description of your job duties:
Do you believe you might be entitled to seek overtime compensation? yes no
Are you or were you paid hourly or a salary?	hourly salary
* If hourly, what is/was your rate of pay per hour?
* If salaried, what is/was your annual salary?
If you are no longer employed, were you laid off, or fired, or did you quit?
Termination date: (if applicable)
If you were fired or laid off, what was the reason your employer gave?
If you do not believe your employer's reason, what do you believe is the real reason?
Were you given any severance pay?	yes no
* Did you sign a release?	yes no
Have you been replaced?	yes no
What is the race, sex and age of your replacement?
Do you believe you are or were being paid less than others performing comparable work? yes no
Explain:
* Number of employees company has:
Are you represented by a labor union?	yes no
If so, which union?
If you believe that you have discriminated against, what type of discrimination is it? (Please check all that apply) Race Sex Pregnancy Religion Age (Please make sure you included your age at the top of the form) National Origin
What is your national origin?
Disability
What is your disability?
Other
What makes you believe you have been discriminated against?
Brief description of the events leading you to contact us, including whether you have been terminated, suspended, demoted, transferred, or disciplined:
Date of most recent event described above:
Are you complaining about sexual harassment?	yes no
If so, is the harasser a supervisor or co-worker?
If so, describe the type of harassment:
If so, did you complain to anyone in management:	yes no
If so, to whom did you complain? (Supervisor, District Manager, Human Resources, etc.)
Do you believe that you have been retaliated against for complaining of discrimination / harrassment? yes no
If so, describe:
Is the company for which you work or worked publicly traded? yes no
Have you witnessed anything you considered to be an inappropriate or unlawful business practice? yes no
If so, did you report it? yes no
What kind of business practice?
When did you report it?
To whom?
What happened?
Do you believe you have been denied your rights to take family or medical leave? yes no
Has an EEOC charge been filed?	yes no
If yes, date filed:
Has a right to sue letter been issued?	yes no
If yes, date issued:
Is there any other information that may help us understand why you feel your rights have been violated?
* Do you have an employment contract?	yes no
* Have you ever signed an arbitration agreement with this employer? yes no
* Have you ever signed a non-compete or non-solicitation agreement with this employer? yes no
* Are you currently represented by another attorney on this matter? yes no
If so, who is the attorney?
* Were you previously represented by another attorney on this matter? yes no
If so, who is the attorney?
If so, why is that attorney not currently representing you?
* Have you filed for bankruptcy?	yes no

Law Offices of Debra E. Schwartz, LLC, 945 E. Paces Ferry Road, Suite 1770, Atlanta GA 30326
Phone: 404-842-7262 Fax: 404-842-7277, E-Mail des@GAEmploymentLawyers.com

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