Employment

Please fill out the form below as best you can—it’s not a perfect form. With this form we want to get to know who you are, understand what you have experienced, the reason(s) you are reaching out to us, and how we can be most helpful.

There are areas of this imperfect form where information must be very limited. There is a character limit, and you will not be able to submit the form if you surpass it. For the questions with more brief answers, such as preferred method of contact, there is a character limit of 255 characters. There are a few areas that are long-form and can accept multiple lines of information, if that space is needed. If you are having trouble submitting your form, please review your answers for length first (any offending spaces may be marked in blue instead of red) and place any information that doesn’t fit in the limited response areas into one of the long-form response areas, like the final question of the form. You may even wish to copy and paste your answers from a separate Word/Google Doc/Note/etc. because technology and human errors happen and some of your information may be deleted if you experience any trouble with the form.

Additionally, please note that while any single file type may be uploaded (PDF, Word doc, etc), the file must be under 50 megabytes. If you would like to attach multiple attachments, they must be compressed and uploaded as a zip file.

Please call us if you have repeated issues with the form, 737-377-9557.

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No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

Contact information: Client

Prefix

First name

Middle name

Last name

Date of birth

Company

Emails

Email Address

Type

Addresses

Street address

City

State/Region

Zip/Postal code

Address type

Phone numbers

Phone number

Type

Acknowledgement & Case Details

ACKNOWLEDGEMENT AND ACCEPTANCE I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information. I agree to receive communications by text message about my inquiry. You may opt-out by replying STOP or ask for more information by replying HELP. Message frequency varies. Message and data rates may apply. You may review our Privacy Policy to learn how your data is used. Our privacy policy can be found at the bottom of our website here: https://saffoldlaw.com/

Preferred Name

Preferred Pronouns

Reason(s) for contacting us:

Legal History

Do you have any arrests and/or convictions on your record?

Yes No

Do you have any liens against you?

Yes No

Employment Information

What is the name of the employer we are going to discuss?

What city and county is the employer located in? (e.g. Austin, Travis County, Chicago, Cook County)

How many employees did your employer have?

Are you currently employed by the company we are going to discuss

Yes No

Do you work for a public company and have evidence that it is committing serious fraud? (ie: submitting fraudulent cost reports, lack of medical necessity, upcoding, kickbacks, etc)

Yes No

Do you work for a company that receives federal funds and have evidence that it is committing serious fraud on the government? (ie: Medicare fraud)

Yes No

Where did you primarily perform your job? (e.g. Office location, remotely from home)

What is/was your job title?

Are/were you a union member?

Yes No

How long have you worked for this employer?

Approximate Start Date

Approximate End Date (if applicable)

Select your total annual pay (including everything- pay, overtime, commission, bonus, etc.)

How were you paid? (Hourly, Salary, Other, Base + Commission)

Which types of compensation did you receive? (Equity, Commissions, Overtime Pay, Hazard Pay, Other)

If you are a commissioned employee, do you make more in salary than in commission?

Yes No

Incident Details

What are/were your job duties?

Was there any disciplinary action taken toward you during your employment?

Yes No

What is the latest date you were fired/harassed/mistreated?

In one sentence, what happened?

If you believe that you were wrongfully terminated based on discrimination please explain why and provide specific examples of that discrimination, including approx. dates. (e.g. my employer directly stated in an email that they wanted to get rid of me due to my old age and I am 65)

Were you given a severance agreement or any form of termination paperwork?

If YES, what kind of document were you given and did you sign it?

Describe your lost wages and other damages

Complaints Filed

Have you filed any complaint(s) with a court or government agency? If so, which ones?

Equal Employment Opportunity Commission (EEOC) Texas Workforce Commission (TWC) Illinois Department of Human Rights Other

If you have filed with the EEOC, please attach any related documents (Position Statement, Right to Sue, Charge of Discrimination, etc)

Conclusion

Desired Outcome - What would you like to see happen to resolve this matter?

If you have separated from your employer, have you been able to find a new job?

Yes No

Have you reached out to another attorney about this case?

Yes No

What else haven't we asked about that you'd like us to know?

Source

How did you find out about this law firm?

Another attorney/lawyer Friend/family Current or former client (including you) Print Media (ie: Austin American Statesman, Austin Women's Magazine) Television Interview (ie: KUT, KVUE, KXAN) Social Media (ie: LinkedIn, Twitter, Instagram, Facebook, Yelp) Non-Profit Partner (NELA, TELA, Times Up, Legal Network for Gender Equality) Internet Search Engine (Google, Bing, etc.)

If you have any relevant documents you wish to share about your case, please attach them below.

THANK YOU
Thank you so much for contacting our law office! Please read the privacy policy below, and then fill out this form in its entirety.

In order to be contacted by the firm, you must complete this form first. By completing the intake form for Saffold Law, PLC (“the Firm”), you agree that you have reviewed and agree to the following:
1. While the Firm may give advice where appropriate, the Firm is not agreeing to represent you in any disputes at this time.
2. You may either be called or e-mailed by the firm for follow-up information. If you are called by the firm for any follow up conversation you may not record the phone call.
3. If you are not available at the time of the follow up phone call, a message will be left and follow up will be at the Firm's discretion.
4. The follow up phone call shall last no longer than 15 minutes. The 15 minute time-limit may be extended solely at the Firm's discretion.
5. If the attorney conducts the phone call, they will not review documents as part of the 15 minute follow up. If you wish to have documents reviewed, please select the Employment Law Advice and Strategy Session, which is a paid consultation.

REQUIRED NOTICE: The State Bar of Texas investigates and prosecutes professional misconduct committed by Texas attorneys. Although not every complaint against or dispute with a lawyer involves professional misconduct, the State Bar Office of the General Counsel will provide you with information about how to file a complaint. For more information, please call 1-800-932-1900. This is a toll-free phone call. Thank you so much for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We will contact you as soon as possible with any updates. Please click the SUBMIT button below when you have finished answering all questions. ACKNOWLEDGEMENT AND ACCEPTANCE I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.