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Long Intake Form English

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Gender

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Who referred you to AM+F ?

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If you were not referred, how did you find out about us?

Preferred Attorney

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Name of Employer(Required)

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How Many Employees?

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Date of Hire

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Job Title(Required)

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Most Recent Salary(Required)

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Union

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What harm (fired, laid off, demoted, reassigned or transferred unfairly, not promoted, not accommodated, reasonable request denied, etc.) was inflicted on you?

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

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

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Did You Resign?(Required)

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Did you ever complain to your employer about the harmful actions against you (either orally or in writing)? If yes, on what date(s) and to whom did you complain?

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Explain why you are contacting AM+F for possible representation by providing a summary of the reasons why you believe you were treated wrongfully by your employer

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Do you believe you were fired or harmed in some other way for taking a leave of absence?

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Have you ever filed a workers' compensation claim? If so, when (dates)?

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If there is any other information that you wish to provide for AM+F to assess your situation (including offers of severance or settlement), please provide below:

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Long Intake Form English

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