The Law Office of Jack E. Brackney

Attorney and Counselor at Law

(877) 679-5225
jack@brackneylawoffice.com

39-20 59th Street, Suite 2
Woodside, New York 11377

815 Superior Avenue East, Suite 1618

Cleveland, Ohio 44114

Thank you so much for contacting our law office! Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security Number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

Social Security Numbers are most often used to positively identify parties. Most courts require Social Security Numbers of all parties in a case. Some other examples of how this information may be used include:

-initial service
-in court orders
-in required reports or other documents filed with the State

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you!

Contact information: Client

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

Preferred Contact Method

Social Security Number

Driver's License Number

Marital Status

Single

Married

Separated

Divorced

Widowed

Employer Information

Please provide the following information about the employer that is the subject of your claim.

Employer Name

Employer Address

Name of Direct Supervisor

Employer Phone Number

Date Hired

Last Date Worked

How did your employment end?

Was your termination voluntary? (If applicable)

Yes

Job Title

Job Duties

Rate of Pay

Was there a written contract of employment

Yes

Were you a union member while employed?

Yes

Did you ever work more than 8 hours per day or 40 hours per week and not get paid overtime?

Yes

Were you able to take a 10 minute break after every 4 hours of work?

Yes

Were you permitted to take an uninterrupted, duty-free lunch or meal period of at least 30 minutes during your workday?

Yes

Have you filed a complaint with the Labor Commissioner?

Yes

Do you know of other people who worked for the employer you are complaining about who were also denied their lunch/meal or rest breaks?

Yes

How many Full-time employees at the workplace?

Do you believe you were wrongfully terminated?

Yes

Were you a victim of any of the following while employed:

Sexual Harassment

Race or National Origin Discrimination

Gender Discrimination

Pregnancy Discrimination

Age Discrimination

Disability/Medical Discrimination

Sexual Orientation Discrimination

Denial of Medical or Family Leave

Unpaid Wages/Denied Breaks

Name and title of person who harassed you.

Witnesses to complained of treatment?

Yes

Are you aware of anyone else discriminated against or harassed as indicated above?

Yes

Did you ever complain to your employer of how you were being treated at work?

Yes

What was the last date you were harassed or discriminated against?

Have you filed a formal complaint with the Department of Fair Employment and Housing or the EEOC regarding your claims?

Yes

Have you received a “Right-to-Sue” letter from a governmental agency?

Yes

During your employment did you become aware that your employer was engaging in conduct you believed was wrongful or illegal?

Yes

Did you refuse to participate in that conduct?

Yes

Did you complain to anyone about that conduct?

Yes

Have you been able to secure a new job?

Yes

Current Employment Information

Please provide details of your current employment, if applicable.

Current Employer

Employer Address

Employer Phone

Current Rate of Pay

Current Job Title

Current Job Duties

Date Employment Began

How were you referred to our law firm?

Friend or family member

Another attorney

Online search or lawyer directory website

Bar Association

Other

If our law firm ends up representing you in this matter, will you be the person who pays the legal fees?

Yes

ACKNOWLEDGEMENT AND ACCEPTANCE

I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.

THANK YOU

Thank you so much for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We will contact you as soon as possible with any updates.

Please click the SUBMIT button below when you have finished answering all questions.