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Request a Free Telephone Consultation
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First Name
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Last Name
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Your answer
Email Address
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Telephone Number
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Age
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Length of Service
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Approximate Annual Salary
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Name of Employer [confidential]
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Are you a member of a Union?
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No
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Have you been terminated? Or still employed?
Terminated - With Severance Package
Terminated - No Severance Package
Still Employed
Laid Off
Other
Have you experienced harassment or discrimination at work? (Check all that apply)
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Minor workplace bullying (yelling, threats, insults, intimidation etc)
Major workplace bullying (physical harm, threats to safety etc)
Disability discrimination
Age discrimination
Gender/Pregnancy discrimination
Racial or Religious discrimination
Sexual harassment
Unfair demotion or change in job duties
Decrease in compensation or salary
Other
Are you aware of other people at your workplace with the same issue(s)? If so, how many?
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How did you hear about us?
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What city/town do you live in?
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How can we help you? (Please provide full details)
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