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Full Name *

Email Address *

Cell Phone Number *

Preferred Way to Reach YouEmailPhoneText

Name of Employer *

Employer Location (City, State) *

Employee Work Location (if different from employer location)

different demoted, in

Job Title / Position *

Estimated Number of Employees at Employer

Start of Employment Date *

End of Employment Date (or Still Employed) *

Most Recent Annual Salary *

Work Location *

• In-person
• Remote
• Hybrid
• Other

Your Age at the Time of the Events *

What workplace issues have you experienced? *

• Wrongful termination
• Discrimination
• Sexual Harassment
• Other Harassment
• Retaliation for Protesting Misconduct
• Retaliation for Taking Protected Leave
• Wage and hour violations (misclassification, missed breaks, unpaid overtime, off-the-clock work, etc.)
• Other (Explain Below)

Do you believe you were treated differently at work based on any of the following characteristics?

• Race
• National origin / ancestry
• Religion
• Mental Disability
• Physical Disability
• Age (over 40)
• Sex / Gender / Gender Identity
• LGBTQ+ Status
• Marital status
• Military / veteran status
• Pregnancy / Parental Leave
• Other (Explain Below)

Other (please describe)

Briefly describe your situation, in particular the harm that you have suffered (e.g., terminated, demoted, etc.) *

What reason(s) did the employer give for taking the action(s) that it took?

What do you believe are the real reasons your employer took these actions?

List any instance where you informed employer about the harmful actions against you or others.

Describe any documentation you have in your possession that supports your claims, or evidence you know is in your employer's possesion.

Do not be stressed if you don’t have documents, it is very common and not a barrier to bringing a case.

Have you ever filed another employment lawsuit or workers' compensation claim? If so, when?

If there is any other information that you wish to provide that will help us assist in our evaluation, please describe:

How did you hear about Edendale Justice Advocacy, PC? *

I understand that submitting this form does not create an attorney-client relationship. *

• I understand that submitting this form does not create an attorney-client relationship.

I confirm that the information provided is accurate to the best of my knowledge. *

• I confirm that the information provided is accurate to the best of my knowledge.

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Disclaimer: The use of the internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.