Directions/Contact Information

Schleier Law Offices, P.C.
3101 North Central Ave., Suite 1090
Phoenix, AZ 85012

Phone: (602) 277-0157
Fax: (602) 230-9250

Meeting Request Form

Welcome to Schleier Law Offices Case Interview for individuals who have employment related legal claims. We ask that you submit the information about your potential case so that we may assess the merits of your claim and determine whether Schleier Law Offices will be able to represent you. Please provide as much detail as you can.

In completing this form you acknowledge that Schleier Law Offices is not offering to represent you at this time or accepting any duty or responsibility to represent you in a lawsuit, mediation or any other legal matter. After receiving the information, we will notify you of whether we are interested in a follow-up conversation or meeting to discuss possible representation of your case.

Your communications during this evaluation process will be treated as privileged and confidential.

When you have finished, click the "Submit" button at the bottom of the page.

Contact information

Name *

	FIRST LAST

Address *

	STREET

	CITY STATE ZIP/POST CODE

	COUNTRY

	Telephone number *
	Please include area code

HOME

	CELL BEST TIMES TO BE REACHED

E-Mail address *

Profession/job title

Current/former employer

	NAME AND LOCATION (CITY & STATE) DURATION OF EMPLOYMENT

Background information

	Are you a member of a union?
	Y   N

	Are you covered by a Collective Bargaining Agreement?
	Y   N

	If so, do you have a copy of the Collective Bargaining Agreement?
	Y   N

	What type of case do you have? (check as many as apply)
	Breach of contract   Wages   Termination   Demotion   Failure to promote   Discrimination   Harassment   Retaliation   Whistleblowing   Other

	If you checked other, please describe the details of your case

Please provide the date the most recent wrongful event occured

	Have you filed a charge of discrimination with the EEOC or the Arizona Civil Rights Division?
	Y   N

	Has a determination been issued?
	Y   N

If yes, then when was the determination issued?

	Has a Right to Sue been issued?
	Y   N

If yes, then when was the Right to Sue issued?

About your case

	If your case is for breach of contract, is there a written copy of the contract or agreement?
	Y   N

	Do you have a copy of the agreement?
	Y   N

	If your case is for wages, do you have a compensation plan?
	Y   N

	Do you have a copy of the compensation plan?
	Y   N

	Do you have a copy of the employer's personnel policies or procedures?
	Y   N

	If you have been a victim of discrimination, please check the boxes that describe the type of discrimination suffered
	Sex   Race   National Origin   Religion   Age   Disability   Other

	If you checked "other", please describe the details of the discrimination

	If you have been a victim of harassment, please check the boxes that describe the type of harassment suffered
	Sex   Race   National Origin   Religion   Age   Disability   Other

	If you checked "other", please describe the details of the harassment

	If you have been a victim of retaliation/whistleblowing, please check the boxes that describe the basis of retaliation
	Report of discriminatory behavior   Report of violation of law/rule   Refusal to engage in an illegal activity   Attempt to enforce a legal right you have   Other

	If you checked "other", please describe the basis of retaliation

	Please describe in 75 words or less the reason you are seeking legal advice, and include all pertinent dates

Additional questions about your claim

What was your salary/hourly wage with the employer in question?

If the case involves a loss of wages, commissions, bonuses, what is the total you believe is owed to date?

If the case involves a termination, how long have you been unemployed?

If reemployed, what is your current salary/hourly wage?

	Is there is a significant difference between the benefits provided by your new employer and the employer in question?
	Y   N

	If "yes", please describe the difference in benefits between employers

	Have the events described above caused you any emotional distress?
	Y   N

	If "yes" then please describe the emotional distress suffered

	Have you sought any counseling or medical care?
	Y   N

	If "yes" then please describe the counseling or medical care received

Referral source

	The following information is for our law firm's use. How did you hear about Schleier Law Offices?
	Personal referral   Attorney referral   Article   Speaking engagements   Search engine/portal   Yellow pages   Bar associations   EEOC referral   Other