Gabroy | Messer Intake Gabroy | Messer Intake Intake form Step 1 of 9 11% Gabroy | Messer Intake Thank you very much for reaching out to our law offices. Please fill out the following questions for an intake and conflict check with our office. Once the form is completed, our office will be notified and will contact you with your preferred contact method. If you have any questions, please call our office at (702) 259-7777. Communication of information by, in, to or through this form and your receipt or use of it (1) is not provided in the course of and does not create or constitute an attorney-client relationship, (2) is not intended as a solicitation, (3) is not intended to convey or constitute legal advice, and (4) is not a substitute for obtaining legal advice from a qualified attorney. All deadlines/statute of limitations are your responsibility. You should not act upon any such information without first seeking qualified professional counsel on your specific matter, and you are advised to seek a second opinion. The hiring of an attorney is an important decision that should not be based solely upon website communications or advertisements.Email(Required) Name(Required) First Last Phone(Required)Preferred method of contact?(Required) Email Phone How did you hear about our office?(Required) Google Search Yelp Lawyers.com Media State Bar Friend/Family Website Attorney Referral Other Which attorney referred you to our office? Other referral source Please let us know how you heard about our office. Please provide the following information for the employer you are contacting our office for. Name of Employer(Required) Do you do any work in the medical field?(Required) Yes No Do you know or suspect that there are any issues with appropriate billing for those who receive medical care?(Required) Yes No Please explain as best as you can.(Required)When did you start with the company?(Required) MM slash DD slash YYYY Job Title/Position(Required) How many hours do you work per week?(Required)Please enter a number.Are you paid hourly or salary?(Required) Hourly Salary What is your hourly rate?(Required)Do you work more than 40 hours a week?(Required) Yes No Are you paid overtime (time and a half)? Yes No Other Please describe other overtime Are you offered health insurance?(Required) Yes No Other Please describe other insurance What is your typical work schedule?(Required) Set Schedule Varying Schedule How many hours do you work in a day?(Required)What is your typical work schedule?(Required) Do you have records of your pay stubs?(Required) Yes No Other Describe other pay stubs(Required) Do you have records of your timesheets?(Required) Yes No Other Describe other timesheet records(Required) Do you clock out for lunch?(Required) Yes No Are you required to work through your lunch break while off the clock?(Required) Yes No How long are your lunch breaks?(Required) Are you allowed rest periods?(Required) Yes No Other Describe Other for rest periods(Required) Do you perform any type of work before clocking in or after clocking out?(Required) Yes No Please explain the tasks and the amount of time it takes.(Required) Number of employees within the company(Required) 1-14 15-50 50-100 100+ How many employers have you had in the past two years?(Required) In addition to your income, do you receive commission, tips or bonuses?(Required) Yes No What are they?(Required) Commission Bonus Tips Other Describe Other Commission, Bonus, Tips(Required) Are your commission/bonus/tips guaranteed?(Required) Yes No Other Describe Other guarantee of commission, bonus, tips(Required) What are your commissions and/or bonuses based on?(Required) Are the tips individually distributed or a part of a tip pool?(Required) Individually distributed Tip Pool Other Describe Other tips individually distributed or a part of a tip pool(Required) Do any non-tipped employees participate in the tip pool? (i.e. management, owners, supervisors)(Required) Yes No Other Describe Other non-tipped employees participating in the tip pool.(Required) What is the status of your employment?(Required) Employed Laid-off Terminated Resigned Other Date Employment ended(Required) MM slash DD slash YYYY Reason for termination/lay-off specifically on termination notice(Required) Did you receive a written notice for your termination/lay-off?(Required) Yes No Have you had any previous write-ups or disciplinary actions before your termination/lay-off?(Required) Yes No Other Other for previous write-ups or disciplinary actions.(Required) when did you receive the write-up/disciplinary action?(Required) MM slash DD slash YYYY What was the reason for the write-up/disciplinary action?(Required) Were you paid your final wages?(Required) Yes No Other Other for Were you paid your final wages?(Required) Were you offered any type of severance or separation agreement?(Required) Yes No Other Other for Were you offered any type of severance or separation agreement?(Required) Did you sign a severance agreement and accept payment?(Required) Yes No Other Other for did you sign a severance agreement and accept payment?(Required) Work-Related InjuriesHave you ever been injured at work?(Required) Yes No Date of the injury - Drop Down(Required) MM slash DD slash YYYY How did the injury occur?(Required)Did you file a C4 form at the time of the injury or report to your supervisor?(Required) Yes No Other Other for Did you file a C4 form at the time of the injury or report to your supervisor?(Required) Were you sent to Concentra or your employer's doctor for an evaluation or did you see your own doctor? Concentra Personal Doctor Other Other for Were you sent to Concentra or your employer's doctor for an evaluation or did you see your own doctor?(Required) Did you apply for Workers Compensation?(Required) Yes No What is the status of you Workers Compensation?(Required) Do you have a Workers Compensation attorney?(Required) Yes No Who is your Workers Compensation attorney?(Required) What is your current working status?(Required) Full Duty Light Duty Other Other for What is your current working status?(Required) Do you have any restrictions?(Required) Yes No What are your restrictions?(Required) Did your employer grant any accommodations for your restrictions(Required) Yes No Other Other for Did your employer grant any accommodations for your restrictions?(Required) FMLA/ ADA AccommodationsDid you have any recent surgeries, pregnancy, or diagnosed with any medical conditions for you to take FMLA?(Required) Yes No Have you applied for FMLA?(Required) Yes No Other Other for Have you applied for FMLA?(Required) Does your employer urge you to not take FMLA?(Required) Yes No Please explain how they urge you to not take FMLA.(Required) Does your employer retaliate if you take FMLA time off?(Required) Yes No Please explain their retaliation.(Required) Do you have ADA Accommodations?(Required) Yes No Does your employer make or try to make reasonable accommodations?(Required) Yes No Other Other for does your employer make or try to make reasonable accommodations?(Required) Discrimination and/or HarassmentDo you feel discriminated in the work place?(Required) Yes No Please select the following class in which you feel discriminated against(Required)ChooseRaceColorReligionEthnicitySex or Sexual OrientationDisabilityAgeNational OriginPregnancyVeteranOtherPlease describe how you have been discriminated against.(Required)Are you being harassed in the work place?(Required) Yes No Please briefly give a timeline and describe the harassment in the work place.(Required) Government AgenciesHave you filed with a government agency?(Required) None EEOC - Equal Employment Opportunity Commission EEO - (Federal Employees) NERC - Nevada Equal Rights Commission NLRB - National Labor Relations Board Labor Commissioner Department of Labor DETR - Nevada Unemployment OSHA - Occupational Safety and Health Administration What is the status of the claim?(Required) Intake Pending Resolution (UE) Mediation/Settlement Investigation Cause Finding/Right-to-Sue Closed/Right-to-Sue Other Information and file uploadsPlease provide a brief explanation of the issues or concerns you are having and/or what the attorney can assist with.(Required)Please upload any and all of the following documents you have regarding your situation. Policies and procedures (handbook materials), termination notice, anything showing written evidence of discrimination such as emails, etc, anything showing that someone has to show up to work and not get paid, any information on tip pools, any paystubs, any information showing hours worked, any information showing auto-deductions, any pieces of information showing calendars, etc.Files to upload Drop files here or Select files Accepted file types: pdf, jpg, png, gif, Max. file size: 128 MB. NameThis field is for validation purposes and should be left unchanged. Δ Home Write A Review Employment Personal Injury Our Team Contact Articles Car Accident Attorneys in East Las Vegas Premier Car Accident Attorneys in the Arts District
