Client Information Form

Please answer all questions to the best of your ability.

Client Information Form

Legal Name

Date of Birth

Address

Phone

Employer Name

Employer Address

Employer Phone Number

Are you currently employed with this employer?

Yes

Your Position/Title

Years of Service

Latest Date Mistreated/Terminated

Your Salary or Hourly Wage

Manager/Supervisor's Name

Employer's H.R. Representative

Other Individuals Involved - Please list names of other supervisors, co-workers, and/or employees that may be involved in your case and a brief description of how they are involved.

Description of Mistreatment - Briefly describe the mistreatment you sustained, i.e. discriminatory, retaliatory or otherwise wrongful. Identify also whether you were subjected to termination, suspension, harassment, demotion, pay change, bullying, etc.

Do you possess a physical and/or emotional health condition for which you have received medical treatment and/or taken medication in the past 12 months?

Yes

If Yes - Please identify the condition and treatment you are currently dealing with: Short answer

Law Offices of Albert F. Kuhl

9393 W. 110th St., Building 51

Suite 500

Overland Park, KS 66210

Tel: 913.638.8022

Fax: 913.369.7714

Contact us

If you need the services of an attorney for help with a potential discrimination / harassment case, please complete the following information below to schedule an appointment.