GHNY Law Intake Form

Bryan D. Glass, Esq. or Jordan F. Harlow, Esq. will contact you shortly.
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Type of Discrimination {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Interested in an in depth 1 hour consultation? Consultation cost is $175 and can be performed in person, through video conference or over the phone for convenience. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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(ex. I worked for 10 years with positive reviews until I made complaints about my supervisor and now I'm targeted and harassed.)

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GHNY Law Intake Form

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Type of Discrimination {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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The email has been sent.

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GHNY Law Intake Form

Bryan D. Glass, Esq. or Jordan F. Harlow, Esq. will contact you shortly.
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If applicable, choose one choice that applies. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Reason for Contact {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Type of Discrimination {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Interested in an in depth 1 hour consultation? Consultation cost is $175 and can be performed in person, through video conference or over the phone for convenience. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Brief description of situation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What type of consultation are you interested in? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Check all the days you are available. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please indicate your available times on the days selected above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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