Intake Questionnaire - INITIAL - Peebles Law Offices

Please fill in the information below and Peebles Law Offices will get back to you shortly.

Name

First

Last

Primary Phone

Email

Address

Address Line 1

City

State

What happened? (include the date, location, and description of what happened)

My case involves:

Bodily injury
Employment or termination
My insurance company or damage to my house or business

Choose what best describes your employer's conduct:

I made complaints to my employer about safety violations or illegal activity at my workplace, and my employer retaliated against me.
My employer discriminated against me because of at least one of the following reasons: my race, color, disability, age, pregnancy, sex, sexual orientation, religion, or national origin.
My employer treated me wrongfully and unfairly for reasons that did not involve complaints about safety violations or illegal activity at my workplace, and which did not involve discrimination against me because of my race, color, disability, age, pregnancy, sex, sexual orientation, religion, or national origin.

Think of all the work locations that your employer has within a 30 minute drive from where you worked, including your location. When you add up the total number of employees at all locations, do you estimate they all add up to:

less than 12 employees?
12-20 employees?
21-50 employees?
over 50 employees?

How did you first learn of Peebles Law Offices?

SMS Messaging – You may also opt in to communicate by text messaging if you choose.

By checking this box you are opting into SMS from a web form or other medium, you are agreeing to receive SMS messages from Peebles Law Offices. This includes SMS messages for customer care. Message frequency varies. Message and data rates may apply. See privacy policy at https://peebleslawoffices.com/privacy-policy/. Message HELP for help. Reply STOP to any message to opt out.

Intake Questionnaire – INITIAL