Questionnaire - Tanner & Associates - TANNER AND ASSOCIATES, PC

Intake Questionnaire

All potential clients are required to fill out an intake questionnaire before meeting with an attorney. Please fill out the questionnaire to the best of your ability. If a question is inapplicable, simply write N/A. All information you provide will be maintained as confidential.

Please do not send any documents along with your completed Questionnaire, except for documents specifically requested in the Questionnaire. Do not send any original documents.

By submitting this questionnaire, you acknowledge that you understand that you are submitting this information to Tanner and Associates, P.C. for consideration only. One of our attorneys will review your completed Questionnaire and we will attempt to contact you if we believe a consultation is appropriate. By reviewing your questionnaire, the firm is not establishing an attorney-client relationship with you and is under no obligation to represent you in this matter. You understand that the firm may decide not to schedule a consultation with you and, even if you have a consultation with one of the firm’s attorneys, the firm may decide not to take the case which you have requested that the firm review.

You may submit the questionnaire through the form below, or alternatively you may download the questionnaire (available in English or Spanish) and send it by fax, mail or email.

Questionnaire (PDF)
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Questionnaire (doc)
File Size:	53 kb
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En Español (PDF)
File Size:	102 kb
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En Español (doc)
File Size:	59 kb
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Intake Questionnaire

All information you provide will be maintained as confidential.
Please type your responses and answers to all questions.
Incomplete or illegible questionnaires will not be reviewed.

* Indicates required field

Date *

Name *

First

Last

Gender *

Male Female

Address *

Line 1

Line 2

City

State

Zip Code

Country

Driver's License Number *

Driver's License State *

Email *

Home Phone *

Work Phone *

Mobile *

Age *

Date of Birth *

Marital Status *

Spouse's Name *

Spouse's Employer *

Identify the person who referred you to us by name or other source of referral *

Identify employer, company or individual with which you have a legal problem by name *

Approximately how many employees does the employer have nationally? *

Locally? *

How long were you (or have you been) employed by this employer? *

Effective date of hire *

What (was/is) your salary? *

What (was/is) your job title? *

State whether you have been: *

If other, please specify: *

Date Notified *

Effective Date of termination or demotion *

What is the name of the person who notified you of the adverse decision? *

What is this person's position? *

Who do you think really made the decision (e.g., the person who really wanted you terminated)? *

What was the stated reason for the adverse decision? *

What do you think is the most important real reason for the decision to discharge you or take other adverse action against you? *

Are you represented by a labor organization? *

If so, identify the union and state whether a grievance involving this matter has been filed on your behalf. *

In case of refused application, what job were you seeking? *

In case of termination, how much, if any, severance pay were you given? *

Have you signed a release or waiver? *

What is the age, race and sex of your replacement? *

Have you found other employment? *

Yes (if so, state the name of your new employer, date of hire, and the amount of your new salary below) No, but expect to find employment soon No, and do not expect to find employment soon (please explain)

Explain (if applicable): *

Do you believe your case may involve any of the following?

1. Age discrimination *

2. Sex discrimination *

3. Sexual harassment *

If you believe your case may have involved sexual harassment, state the name, sex, age and job title of each person who sexually harassed you. *

4. Disability discrimination *

If so, what is your disability? *

Does the company know you have a disability? *

5. Race discrimination *

6. National origin discrimination *

7. Religious discrimination *

8. Libel or slander *

9. Invasion of privacy *

10. Breach of contract *

If so, please attach a copy of your employment contract.

11. Fired for refusing to perform an illegal act *

If so, what did you refuse to do? *

12. Discharged for filing a worker's compensation claim *

13. Another person or company got you fired *

14. Failure to pay overtime *

15. Other (please specify) *

At the job in question (the employer you may wish to sue), did you complete a written job application or submit a resume? *

If yes, does it contain any misstatements, important omissions or inaccuracies as to your education, qualifications, criminal record, work history, etc.? *

If yes, please explain. *

Have you ever been convicted of a crime? *

If yes, please explain. *

Have you ever filed for bankruptcy? *

If so, is the bankruptcy proceeding still pending and has the employment claim been listed as an asset of the estate? *

Did you take or keep any confidential company documents or any company property from the job in question? *

If yes, please explain. *

Briefly describe your main complaint or your need for legal services. *

What do you wish to accomplish through an attorney? *

Are you currently represented by an attorney? *

If yes, please state the attorney's name and address. *

Does the employer have a mandatory arbitration policy? *

If so, attach a copy.

Date of EEOC or Texas Commission on Human Rights charge (if any) *

Please attach a copy of the charge and any statement or affidavits you submitted to the agency.

Date of determination letter from EEOC or TCHR (if any) *

Please attach a copy of the determination letter.

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

If yes, please explain briefly and state the deadline. *

Upload File (Only upload information requested above. No additional documents please.) *

Max file size: 20MB

Important: Our provision and review of this questionnaire does not constitute the provision of legal advice or any agreement to represent you. No attorney-client relationship will be formed unless and until both you and Tanner and Associates, P.C. sign a written Legal Services Agreement which sets forth the terms and conditions or this firm's representation. This questionnaire will be destroyed if we do not represent you.

Please click the "Submit" button only one time in order for your submission to be processed.

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