Confidential Intake Form

Step 1 of 9 – General Information

Disclaimer*
Please check the Box to Continue to the next page. By checking the Box and completing the completing the Intake Form you understand and acknowledge that: (1) you are submitting information through the Intake Form solely for the purpose of allowing Thunderbird Law Group PLLC (“Firm”) to review information regarding possible legal representation; (2) completing the Intake Form does not create an attorney-client relationship and the Firm has not accepted any duty to file a lawsuit or take any action on your behalf; (3) the Firm may need further information to make a decision regarding representation; (4) the Firm will contact you if we need additional information or to schedule a meeting to discuss possible representation; (5) the Firm charges a Consultation Fee of $400.00 for an In-Person Consultation, unless you are specifically offered a waiver; and (6) all the information you provide during the evaluation process is privileged and confidential.
- I understand and agree.

Confidential Questionnaire
This questionnaire is meant solely for the use of the consulting attorney for purposes of analyzing and evaluating the prospective client’s case. The contents of this document are therefore protected by the attorney-client privilege and the attorney work product doctrine. It is very important that you be completely truthful, accurate, and complete in answering the following questions.
How did you find us?
Your Name*
First Last
Home Number
Mobile Number*
Work Phone
Your Email:*
Home Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Current Employer
Date current employment obtained:
MM slash DD slash YYYY
You are seeking advice regarding your employment at:
If terminated, list former employer here:
Address of former employer:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How many employees work in the company?

What is your complaint?*
If terminated, state what your employer said its reasons were for terminating you. (If you were told it was a layoff, state the reason your employer gave for selecting you for layoff instead of other employees that hold the same or similar positions):
If terminated, please explain what you believe was the actual reason that the company terminated you. (If you believe the company truly reduced its workforce, and eliminated one or more positions, please explain why you think they chose you for layoff instead of other employees that hold the same or similar positions. In other words, we want to know what you think the motive was, not what the company told you its reasons were.)
If you were laid off, pursuant to a reduction in force, were there other employees that held a position similar to yours that was retained by the company when you were laid off? If your claim is discrimination based on age, race, gender, national origin, etc., please also state the age, race, gender, or national origin of the employees that were retained. For each such employee, please also explain why you think that the employee should have been laid off instead of you. For example, if you were laid off over an employee that had less seniority, less experience, less education or training, state that next to the employee's name. (BE SPECIFIC)
If your employer told you that it fired you for violating some company policy, or disciplinary rule, or regulation (e.g., absenteeism, tardiness, theft, timecard fraud, unsafe workplace conduct, etc.), please list each and every other employee that you believe engaged in conduct of the same severity and frequency, but was not fired. If your claim is discrimination based on age, race, gender, national origin, etc., please also state the age, race, gender, or national origin of the employees that were retained. If your claim is based on whistleblowing, please state whether the employees that were not disciplined as severly as you also engaged in whistleblowing. Also state what misconduct each of the listed employees actually engaged in, when, how frequently, and the name of any supervisors that knew the employee committed the misconduct that you contend was as severe as that for which you were fired.
Did your employer follow company policy and procedure in handling your dispute?
- Yes
- No
- I don’t know
Do you feel race, age, sex, national origin, religion, sexual orientation, pregnancy, disability (physical or mental), or talking a medical, disability or pregnancy leave of absence was the cause of this difference in treatment?
- Yes
- No
- I don’t know
If you believe that any of the above-listed characteristics might have motivated the employment action taken, please describe in detail, each and every fact upon which you base that conclusion. Possible evidence may include the following: (a) Statements or remarks by management: Examples of possible evidence of racial motive include, racial comments, stereotypes, jokes or comments by management, or comments by co-workers, of which management knew about. Also comments that you are not a “team player” might indicate a retaliatory motive; (b) Others who were treated more favorably in similar situations: If other employees who did not have your protected characteristic (i.e., were not of the same race, age, gender, or were not disabled), were treated better in similar situations, that may show discriminatory motive. For example, if you are a woman and were fired for being late, the fact that other male employees were also late but were not fired would constitute evidence of discrimination; (c) Statistics: How many total employees at your company vs. how many employees of your gender, race, age or national origin. For example, if your company has only 2% Hispanic employees, but 25% of the applicants are Hispanic, that would tend to prove racism. Also, if Hispanics, or women, or older workers make up only 10% of the workers at your company, but 50% of the terminations or suspensions, that would tend to support an inference that the terminations or suspension decisions were motivated by some protected characteristic.

confidential intake form

Step 1 of 9 – General Information

Confidential Questionnaire

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