Benezra & Culver, P.C.>Set an Initial Appointment for Employment Case

Set an Initial Appointment for Employment Case

Use the form below to set up an initial appointment for a Employment Case.

PLEASE NOTE: Your responses are protected by attorney/client privilege and will be held in strict confidence.

Section 1: Contact Information

First Name (required)

Last Name (required)

Address (required)

Address 2

City (required)

State (required)

Zip/Postal Code (required)

Contact Phone (Cell or Home) (required)

Your Email (required)

Section 2: Employment Background


Supervisors Names With Title:*

Dates of Employment:*

Current or Final Position:*

Section 3: Adverse Action

Briefly describe all adverse actions (for example termination, demotion, discipline, hostile work environment, failure to promote or other) taken against you by your employer and which are related to your rationale for contacting this firm:*

Section 4: Possible Causes of Action

Please check the box or boxes for each type of legal claim you believe you may have against your employer:

Employment Contract, Separation Agreement, Non-Compete AgreementWrongful TerminationDefamationRace, Color, National Origin and AncestryAgeSex/GenderPregnancy and Maternity LeaveSexual HarassmentSexual OrientationReligionDisability/HandicapRetaliationGenetic InformationCriminal RecordFMLA (Family and Medical Leave Act)Worker’s Compensation RetaliationHIPAA (The Health Insurance Portability and Accountability ActWage & Hour LawsFederal EmploymentState or Municipal EmploymentOther

Section 5: Upcoming Deadlines

If you are aware of any upcoming deadlines, including deadlines to file internal appeals or grievances or deadlines to file administrative charges with the Equal Employment Opportunity Commission or Colorado Civil Rights Commission, please identify those deadlines:

Section 6: Documents:

Please bring all relevant documents to your consultation. At a bare minimum, please bring all applicable employment policies, including employment handbooks, all documents that pertain to any adverse actions taken against you, and any documents that relate to any complaints made regarding your treatment at work. Errr on the side of bringing too many documents as failure to bring all relevant documents will impede and delay our ability to provide you with an opinion regarding your potential claims.