Intake Form

Tell me about why you are looking to contact an attorney...

I know first-hand how difficult it is to face the process of filing a grievance, dealing with HR or Internal Affairs, filing with EEOC or the Human Rights Bureau and finding an attorney. It is a process of escalation with each step presenting its own challenges. Each step is a venture into the unknown. I'm here to help guide you.

If you are dealing with this process, you may have called numerous attorneys before getting in touch with me. I work in direct collaboration with attorneys to help prepare you for their representation and to help you have a more streamlined, service-oriented and informed process.

The first step is to conduct a thorough intake and assess your current readiness for an attorney. I am motivated to answer your questions, learn about your experience and guide you through the next steps in the process - to give you the information to decide if continuing with litigation is right for you.

If you want to pursue litigation and are not yet in a position to acquire representation, I can assist you in taking the steps that attorneys will want you to have completed prior to representation and help you articulate your experience to best communicate what happened. Then, help you determine your next steps and, when you're ready, find you an attorney that is suited to your future case. Please keep in mind that I am not an attorney, nor am I able to give legal advice. My job is to inform you of the facts and let you decide what is best for you.

I will be your guide in efficiently preparing you for the litigation process and making sure you are informed. I collaborate directly with local attorneys for this service and it is free to you through the intake and evaluation process.

If you choose, I will take you through the entire process up until you sign a contract with your attorney, for an additional fee. Using these services will help your chances of being able to obtain representation on a contingency basis. It took me months to find an attorney, then I experienced the loss of a $7,000 retainer before having the good fortune to be taken under the wing of an attorney who found me someone to represent me on a contingency. My goal is to find you representation and advocate for you with the attorneys whom I am affiliated - and also prepare you for their representation so they are able to work more efficiently to help you and others who need them.

All decisions are solely yours regarding this process: how you proceed with your employment, your future litigation and/or how you choose to move forward with your situation. I will give you the most accurate and informed information possible and be your advocate along the way and a liaison between you and the attorneys so you don't have to spend so much time trying to find and get information from attorneys - you can work on moving forward. This is a difficult situation and I am here to make it easier.

Question Title

* 1. Tell me a little about yourself...

Name *

Company

Address *

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

Question Title

* 2. Who referred you to The Advocate?

Question Title

* 3. Were you referred to a particular attorney?

Yes

If yes, who referred you and who were you referred to?

Question Title

* 4. Are you currently represented by an attorney

Yes

If yes, who?

Question Title

* 5. Please share your reason for contacting me today

Question Title

* 6. What company are you having a problem with? (Who are you potentially looking to sue?)

Question Title

* 7. Approximately how many employees does this company have locally?

Less than 4

Less than 15

More than 15 but less than 50

Over 50 but less than 100

Over 100 but less than 500

Over 500 but less 1,000

Over 1,000 employees

Is the company local, national or international?

Question Title

* 8. What is/was your length of employment with the company in question

0-1 Years

1-3 Years

3-5 Years

5-10 years

10-15 years

15-20 years

More than 20 years

I did not work for this company

Question Title

* 9. What was your date of hire with the company in question?

Please enter exact or approximate mm/dd/yy

Date

Question Title

* 10. What was your job title at the time of hire?

Question Title

* 11. What is your current job title, or your title at the time you left or were fired?

Question Title

* 12. Which of the following categories best describes your employment status if you are/were employed by the company in question?

Employed with the company in question, want to stay employed with them, and am having an issue that I want to try and solve

Denied employment at the place in question

The company presented me a severance agreement and I don't whether or not to sign it

Employed with the company in question, but demoted

left my employment at the place in question

I was fired from the place in question

I was constructively discharged from place in question

I am disabled, not able to work due to an incident at the place in question

Any additional information including dates of fire, demotion, leaving the place of employment and what position demoted to if demoted. If denied a promotion, what position you were applying for. For any adverse decision listed above, what did the company tell you was the reason and who notified you of this reason (name and position)?

Question Title

* 13. If you were denied a job, what job were you seeking

Question Title

* 14. If you were terminated, were you given severance pay?

Yes

If yes, how much?

Question Title

* 15. If fired, did you sign a release waiver?

Yes

Not applicable

Details

Question Title

* 16. What is your current pay, or what was your pay at the time you left the employer in question?

Question Title

* 17. Was/is your pay consistent with others in the company with a similar title or similar experience?

Yes

Not sure

If no, please explain

Question Title

* 18. Were you ever denied overtime, have to work off the clock, or did you have a problem receiving your final paycheck?

Yes

If yes, please explain

Question Title

* 19. If you were fired, what is the age, race and sex of your replacement?

Question Title

* 20. What is the most prominent real reason you think this employer fired, failed to hire or promote you or took adverse action against you?

Question Title

* 21. What is the reason that the employer gave you for the adverse treatment/action?

Question Title

* 22. Is there any behavior, action or accusation that is being made by your employer or former employer?

Question Title

* 23. Are you represented by a labor organization (union)?

Yes

If yes, name the union and whether a grievance been filed regarding this matter?

Question Title

* 24. If no longer working for the company in question, have you found other employment?

Yes

N/A

If yes, what is the name of your new employer, the date of hire and your new salary. If no, do you expect to find employment soon? If no, please explain

Question Title

* 25. If you are having issues with an employer, what type, if any, of reporting have you done?

Contacted an Attorney

EEO/EEOC Complaint

Human Rights Bureau Complaint

Grievance/HR reporting

Verbal complaint to supervisor

Verbal complaint to co-workers

None or Not Applicable

If EEOC or Human Rights complaint, date of charge and determination letter or status of complaint. Attach copy of determination letter if applicable.

Question Title

* 26. Do you believe that your case involves (check all that apply)

Sex Discrimination/harassment

Age Discrimination/harassment

Racial Discrimination/harassment

Discrimination/harassment based on Religious beliefs

Discrimination/harassment due to pregnancy

Discrimination/harassment due to a disability

Defamation

National origin discrimination

Invasion of Privacy

Breach of contract

Retaliation

Termination for filing workman's comp claim

Another person or company got you fired/not hired

Sexual orientation or gender identity discrimination/harassment

Failure to accommodate physical impairment or religious belief

FMLA denial or other issue

Whistleblower

Union activity or concerted activity

Other

if any of the above boxes are checked, what is the name, age, sex and job title of the person who harassed/discriminated against you and specific details about the discrimination (for disability, what disability do you have, for religious, what is your religion, etc.)

Question Title

* 27. Did you take or keep any company documents or any company property from the employer/company in question

Yes

If yes, please specify and explain

Question Title

* 28. Do you have any recordings relevant to your adverse situation at work?

Yes

If yes, please give additional info

Question Title

* 29. Please explain any discipline or retaliation you have received

Question Title

* 30. For the company in question, did you fill out a written job application or resume

Yes

N/A

If yes, does it contain any mis-statments, important omissions or inaccuracies regarding your education, qualifications, criminal record, work history, etc.?

Question Title

* 31. Do you know if you signed an agreement to arbitrate any claims against your employer?

Yes

Don't know

Not Applicable

If yes, please provide a copy of the agreement. When did you sign it?

Question Title

* 32. Have others at the company in question been treated similarly to you?

Yes

I don't know

Question Title

* 33. If yes to the previous question, how many people would you estimate have received similar treatment and what do they have in common with each other?

Question Title

* 34. Are you:

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

Question Title

* 35. What is your age?

Under 18

18-28

29-39

40-50

51-64

65+

Question Title

* 36. What is your marital status

Unmarried, single

Unmarried, partnered

Married

Divorced

Separated

If separated, please provide details

Question Title

* 37. Do you identify as a member of the LGBTQ+ community?

Yes

Choose not to answer

Question Title

* 38. Which of the following options most closely aligns with your gender?

Female

Male

Non-binary

A gender not listed here

Prefer not to answer

Transgender

Any information regarding your gender that you would like to share

Question Title

* 39. What is your sexual orientation?

Question Title

* 40. Does your employer know about your gender/sexual orientation?

Yes

I don't know

Explain

Question Title

* 41. Were you born in a country other than the United States?

Yes

Asia

If yes, what country?

Question Title

* 42. Was there ever any overt comment or behavior made by your employer or its employees about your sex, race, religion, gender or abilities?

Yes

Please explain

Question Title

* 43. What do you want to accomplish?

I want compensation for what happened

I want to file a complaint in order to try and change my situation at work

I want my job back

I want to leave my job, but am concerned about my reputation being ruined and/or not being able to find employment

I want to keep my job, but need some things to change

Other

Other (please specify), or elaborate on other options chosen

Question Title

* 44. Are you aware of any deadline with respect to your need for legal advice or representation?

Yes

If yes, briefly explain and state deadline

Question Title

* 45. I understand that LeAnne Gomez is not an attorney, nor is she qualified to give legal advice. This is a problem-solving and data-gathering experience and LeAnne Gomez is not liable for any outcomes related to these interactions. All decisions are solely mine regarding my employment and/or how I choose to move forward. Any and all information I choose to share regarding my experience is voluntary and truthful. I understand that none of my personal information will be shared without my consent.

Yes, I understand and agree

No, I do not agree or I do not understand