Online Consultation: Employed

Step 1 of 8

Personal Data

Salutation

First Name Please enter your first name.

Last Name Please enter your last name.

Marital Status Single Married Divorced/Separated Widowed

Spouse's First Name

Last Name

Number of Children Under 21

Number of Children Over 21

Street Address

Address Line 2

City

State

Zip Code

Email Address

Home Telephone

Fax Number

Race

Gender Male Female

Religion

Date of Birth

Social Security Number

In which country were you born?

If other, please identify

Do you have a disability or believe your employer perceived you as disabled? Yes No

If Yes, please describe the nature of the disability and how it affects you

What would you like our firm to do for you? (Please include any specific questions that you have)

Current Employer Data

Employer

Employer Address

Address Line 2

City

State

Zip Code

Business of Employer

Employer's Phone Number

No. of employees at your work site

Total No. at all worksites

Name of Chief Executive Officer

Name of Human Resources or Personnel Director

Does your employer do business with the State of Ohio? Yes No

Does your employer do business with the U.S. Government? Yes No

Does your employer do anything wrong or falsely in its dealings with either government? Yes No

Does your employer have any written work rules or policies? (If Yes, please provide) Yes No

Union Activity (if applicable)

Name of Union

Have you filed a grievance about the subject matter of this consultation? Yes No

If Yes, what is the status of your grievance?

If No, why Not?

Damages Suffered as a Result of Employer's Actions

Have you lost income or suffered economically as a result of the probelms Yes No

If yes, please describe how much income you have lost to date and how the employer caused the loss.

Is your physical and/or emotional health affected by your employer's treatment towards you? Yes No

If Yes, in what way?

Are you seeking any kind of treatment from a health care professional as a result of the employer's treatment? Yes No

If Yes, identify the health care professional, the dates of treatment and any prescribed medication.

Have you ever been involved in litigation before? Yes No

If so, give dates and the subjects of the lawsuits or charges:

Other Relevant Information Regarding Your Employment

Please provide any additonal relevant information, regarding your employment

Documents

Are you providing any documents to us? Yes No

If Yes, by Fax or Mail? Fax Mail

How Did You Find Us?

Name of person(s) who referred you to our firm

Name of attorney to whom you were referred

Why did you select our firm?