Case Intake Questionnaire Please fill out and submit this questionnaire and we will follow up with you to schedule a free case evaluation with an experienced attorney. Please fill out this questionnaire completely and provide as much detail as possible as this will help the attorney better evaluate your case.
Please note that submitting this form does not create an attorney-client relationship. An attorney-client relationship is only created once a signed fee agreement has been completed between client and attorney.
How did you find/hear about Brad Mancuso Law?*
If you were referred to us by an attorney, please put their name here:
If you were referred to us through word of mouth, who referred you:
What is/was the name of your employer/company?*
In what city do/did you physically work for the employer? *
In what state is/was your employer based/headquartered? *
What is/was your job title?
Please provide a brief description of your job duties.
Approximately, how long did you work for this employer? (Ex: 9 years, 6 months)*
What was the primary way you were paid?
How much were you paid on an annual basis? *
What was your employment classification?
What was your work schedule like?
What is your employment status now with the employer listed above? *
If you answered "Terminated," "Laid-off," "Resigned," or "Retired," what date did this happen?*
If you are currently on a leave of absence, what date did it start?
What kind of adverse actions do you believe were taken against you? (Check all that apply.)*
When was the last time one of these adverse actions was taken against you? *
Why do you believe an adverse action was taken against you? (Check all that apply.)*
If you made a complaint within the workplace, was it made verbally or in writing?
If you made a complaint within the workplace, who did you complain to (person's title)?
If you made a complaint within the workplace, when did you make the complaint?
Did you inform your employer of a disability?
Was the report of a disability given verbally or in writing?
If you made a report of a disability, who did you report it to (person's title)?
What was the disability you reported?
Did you request a reasonable workplace accommodation from your employer?
Was the request for a reasonable workplace accommodation given verbally or in writing?
If you made a request for a reasonable workplace accommodation, who did you request if from (person's title)?
What was the reasonable workplace accommodation you requested?
Did you request medical leave from your employer to care for yourself or a family member? (Including any pregnancy or baby bonding leaves.)
Was the medical leave request granted?
If the medical leave request was not granted by your employer, what was the reason given?
Have you returned from your medical leave?
Have you faced retaliation by your employer for taking your medical leave to care for yourself or a family member? (Including any pregnancy or baby bonding leaves.)
Please tell us more about your employment situation (i.e. what happened that led you to seek legal help)?*
If your employment ended with the employer listed above, have you found new employment?
If you have found new employment, when did it start?
Compared to your income with your last employer, is your income with this new employer more, less, or the same?
If your new income is less, how much less?
