Employment Intake - Secure/Confidential
Welcome to KM&A's secure and confidential client intake form. The first step in your case is extensive information gathering from you. Be extremely thorough and as detailed as possible - the more information we gather the better we can represent you. Try your best even if you aren't sure how to answer a question because it's important this process moves along quickly. Complete this form immediately so we can schedule follow up intakes, interviews, and promptly begin your case.
Contact Information
Name *
Your full legal name
Your answer
Mailing address *
It is critical you notify us immediately if this address changes.
Your answer
Phone number (primary) *
Your best contact number.
Your answer
Phone number (alternative)
Your alternate contact number.
Your answer
Email address *
You must check your email often and it is critical you notify us immediately if it changes.
Your answer
Availability
What is the best time to contact you in the next week for an intake interview?
Your answer
Emergency contact individual & phone number *
Please list someone we can contact if we can not reach you.
Your answer
Date of birth *
Your answer
Employment Information
Company name *
Your answer
Company address *
(or location you were based out of)
Your answer
Job title *
Your answer
Compensation *
What is or was your last rate of pay, bonuses, and benefits.
Your answer
Hours worked per week *
Your answer
Number of Employees *
Job duties *
Describe your regular job duties
Your answer
Start date *
(Approximate by month if you don't have exact dates)
Your answer
End date *
(Approximate by month if you don't have exact dates)
Your answer
What is your current employment status? *
Note: Please remember to let us know immediately if you find new employment.
Claim Information
What is the nature of your dispute(s)? *
Check all that apply.
Required
Employer's termination reason *
What reason did the employer give for termination or what reason did you give the employer for leaving?
Your answer
Did you file yet with the EEOC or PHRC or any other agency? *
If so, when did you file and what is the status? Have you received a "right to sue" letter?
Your answer
Have you been previously represented by another attorney? *
If so, what is the name of the attorney and firm? Why are they no longer representing you?
Your answer
Detailed timeline or "personal statement" [VERY IMPORTANT] *
Describe in detail what lead up to your separation from employment. Be specific with NAMES, DATES, INCIDENTS, and QUOTES. (Use the Enter button to create paragraphs for readability)
Your answer
Witnesses
List names, contact information, and whether the witness will support your claims.
Your answer
Employer's argument *
Play "devil's advocate," and tell us what the employer is going to claim. What is the employer's position? How will they rebut your story?
Your answer
Disciplinary warnings *
Have you had any oral or written warnings in the last two years? Anything that could be construed as a warning? Explain in detail and if you can't remember the date, please approximate. If no warnings, explain that as well.
Your answer
Complaints to supervisors *
Did you file with Human Resources, complain to management, or complain to anyone in the company (including approximate dates)? Explain if so, or explain why you didn't.
Your answer
Background *
Do any of the following apply?
Required
Case resolution *
Describe what you would like to happen to resolve your issue (your preferred outcome):
Your answer
Deadlines & statute of limitations *
Please list any filing deadlines, upcoming statute of limitations deadlines, dates of recently issued decisions, or any EEOC/PHRC right to sue letters.
Your answer
Anything else? (optional)
Please let us know if there is anything you want us to know or that wasn't addressed.
Your answer
Client Confirmations
Confirm representation *
Check the box below to confirm that you have read and agree to the terms of the LSA provided to you and the Universal LSA at https://LawKM.com/LSA and to certify that the information you submit is true to the best of your knowledge.
Required
Document and communication confirmation *
Please confirm you backing up and saving relevant emails, texts, Facebook postings, other social media, and letters or any other communications. If content is on a mobile device, like text messages on a phone, it is urgent they are backed up and submitted.
Required
Attorney interaction and communication *
KM&A prides itself on quick and open communication with clients. However, it is important to understand that litigation and trial work requires deep concentration and we use office hours to ensure the best outcomes for all clients.
Required
Case progress and resolution *
Required
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