Potential Client Questionnaire

How did you hear of us? *Search Engine (Google/Bing/Yahoo)Avvo AdvertisementAvvo WebsiteYelpPersonal ReferralOther

Name *

First

Last

Email Address *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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Cell Phone *

Alternative Phone

Age

Gender

• Male
• Female

Name of Employer(s) *

In what city did your employment occur?

How many employees work for the company / employer *

• 1 - 4
• 5 - 15
• 16 - 50
• 51 - 100
• Over 100

Were you an employee or an independent contractor?

• Employee
• Independent Contractor

When were you hired?

Job Title

What were your job duties?

Most recent salary or hourly wage *

Are / were you a union member? *

• Yes
• No

If yes what is the name of the Union *

Are you still employed with this employer? *

• Yes
• No

If not, were you fired or did you resign? *

If applicable, when did your employment end? *

What reason(s) did the employer give for firing you?

What is the true reason(s) why your employer decided to fire you?

Did you have any poor performance reviews?

If you sued your employer, what do you think they would say in their defense of firing you?

Do you believe that you have been harassed, discriminated against or retaliated against at work for any reason (for example, race, religion, national origin, age, physical or mental disability, medical condition, gender, sex, sexual orientation, or for objecting to illegal conduct—including complaining about discrimination or harassment based on a protected category?) If so, list all facts supporting your claim

Has it been more than one year since the above events took place? *

• Yes
• No

Identify each person who has engaged in an act of harassment, discrimination or retaliation against you, by stating their name(s) and their job title(s):

Have you spoken to, met with, or corresponded with any other attorneys regarding the issue you wish to speak with us about?

• Yes
• No

If so, to whom? What did you say and when? (name and job title):

Are you disabled? *

• Yes
• No

If so, what is/are your disability(ies)?

Have you ever requested an accommodation of a disability from this employer? *

• Yes
• No

If so, what accommodation?

Did you ever complain to your employer regarding their wrongful conduct? *

• Yes
• No

If so, to whom, when and what did you say? (name and job title):

Do you have any witnesses or documents to help you prove your claims? *

• Yes
• No

If yes, describe and include witness contact information, their position at the company, and whether or not they are currently part of your employer’s management:

Have you ever taken a leave of absence from work? *

• Yes
• No

If so, when (dates) and for what reasons?

Do you believe you were fired for taking a leave of absence? *

• Yes
• No

Are/were you paid overtime for working more than 40 hours per week or 8 hours per day? *

• Yes
• No

If not, please explain your duties:

Are/were you given a 30 minute off-duty meal break for each 5 hours that you worked: *

• Yes
• No

Were you aware of any potential performance issues (whether verbal, PIP, written warning, or otherwise)?

Were you reimbursed for work-related expenses (cell phone, uniforms, mileage (other than commuting), travel, supplies, etc.)? *

• Yes
• No

Have you ever sued anyone before or been sued? *

• Yes
• No

If so please explain:

Have you ever filed or are you thinking of filing for bankruptcy? *

• Yes
• No

If so, please explain:

Have you been convicted of a crime in the past 10 years? *

• Yes
• No

If so, what?

Have you ever filed a workers' compensation claim? *

• Yes
• No

If so, when (dates)?

Do you believe you were fired for filing a workers' compensation claim?

• Yes
• No

What was your date of termination?

Were you incarcerated at anytime during your employment with this employer?

Have you found another job since losing the job in question? *

• Yes
• No

If so, when did you start and how much do your earn at this new job?

COMPLAINTS TO GOVERNMENTAL AGENCIES Section

Have you filed a complaint with the Department of Fair Employment and Housing (DFEH) or the Equal Employment Opportunity Commission (EEOC)? *

• Yes
• No

If yes, have you received a Right-to-Sue letter?

• Yes
• No

Have you filed a complaint with the Department of Labor Standards Enforcement ("DLSE"/the Labor Commissioner)? *

• Yes
• No

If yes, what is the status

Did your employer have you sign an arbitration agreement, either as part of a handbook or given to you as a separate document? *

• Yes
• No

Send to Shirazi Law Firm

Note: Although the information you provide to us on this form is confidential, completion and/or submission of this form to us does not create an attorney-client relationship between Shirazi Law Firm (the “Firm”) and you. No attorney-client relationship shall exist until you and the Firm make a mutual decision to work together and make a written agreement stating the specific terms of that attorney-client relationship. While this questionnaire does not create an attorney client relationship, your information will be confidential and privileged. We will not disclose your information and you may not be compelled to disclose your communications with us to anyone.

If you have time deadlines (or statutes of limitations) that are quickly approaching, we cannot guarantee that we will respond in time for us to assist you in filing a lawsuit or administrative agency complaint. You should take immediate action to avoid missing any such deadlines.