UMKC LAWMO Self-Help Intake v2

Self-Help Litigant Intake:

The clinic seeks to support self-represented individuals as they navigate the court system. We share sample forms, legal advice, and research, as part of providing limited scope representation. It is a free service.
Once you submit your intake form, a clinic volunteer will reach out to you by phone to make sure your information is complete. They will then arrange an appointment for you to speak with an attorney from Legal Aid's Volunteer Attorney Project.
Appointments are generally available Monday to Friday, from 10 am to 2 pm.

Personal Information
What is your name? *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
County *
How did you hear about us? *
Please specify *
E-mail *
Phone Number *
Are you a U.S. Citizen *

Yes No
Are you a Lawful Permanent Resident or green card holder? *

Yes No
If you are a U.S. citizen, please sign below *

(you can sign with your mouse or finger) Clear

Household Information
How many children live with you?
Only include children you are legally responsible for.
Age 1 *
Age 2 *
Age 3 *
Age 4 *
Age 5 *
Age 6 *
Age 7 *
Age 8 *
Age 9 *
Age 10 *
Are you legal guardian or payee of an adult in your household? *

Yes No
How many adults are you the legal guardian or payee of? *

Household Income Information
What is your monthly household income?

This clinic is free. Financial grants make our services available, and ask that we document efforts to serve folks in need. This information enables us to continue to provide free assistance.

You will be assisted regardless of your income level.
Wages *
Before taxes and other deductions. Enter Zero if no wages.
Per
How Many Hours Per Week?
Spouse’s Wages *
Before taxes and other deductions. Enter Zero if no wages.
Are your spouse’s wages per
How Many Hours Per Week?
Supplemental Security Income (SSI) *
Enter Zero if no supplemental security income.
Child Support *
Dollar amount received. Enter Zero if no child support.
Social Security Disability Insurance (SSDI) *
Disability Check. Enter Zero if no SSDI.
Social Security Retirement or Widow’s benefits *
Enter Zero if not applicable.
Other household income
Dollar amount received
what kind of income is it?
What is the value of your household assets (if applicable)?
Bank Accounts *
Enter Zero if no bank accounts.
Your Home Value *
Enter Zero if you don't own a home
Other Property *
Enter Zero if no other property.
Other Property Description *
What kind of property is it?
Vehicle *
Value of your car if you were to sell it today? Enter Zero if no vehicle.
2nd Vehicle *
Value of 2nd car if you were to sell it today? Enter Zero if no 2nd vehicle.
Other assets such as stocks, bonds, CDs *
Enter Zero if no stock, bonds, or CDs. Don't include value of your retirement account
other asset description *
What kind of asset is it?
What are your monthly household expenses, in the following categories (if applicable)?
Medical Supplies
Medicines
Health Insurance
Child Care
Gas to go to Work
Gas only
Other Medical and Work Expenses

Limited Scope Retainer Agreement
UMKC-LAWMO SELF-HELP LAW CLINIC

Limited Scope Retainer Agreement

This agreement is made between {whatIs3} and the UMKC-LAWMO Self-Help Law Clinic:
1. Services Provided. The Lawyer will assist Client with: {whatKind138} issue
2. No Fees. Client understands that he/she will not be charged any fees for the services received.
3. Limited Scope of Representation. Client understands that after his/her appointment, he/she is representing him/herself in the matter described above and will be responsible for handling any further action that needs to be taken in the case. Neither the Lawyer, Legal Aid of Western Missouri staff, the University of Missouri-School of Law staff or students have agreed to provide representation or assistance beyond the date of the appointment or with any other legal problem. Any additional assistance will require a new signed retainer agreement with the UMKC-LAWMO Self-Help Law Clinic.
4. Client Cooperation. Client agrees to cooperate with the Lawyer during the meeting and provide the Lawyer with all information and documents that Client has concerning the case. Client agrees to provide only truthful information in responding to interview questions, filling out forms, questionnaires or other documents.
5. Confidentiality. Client understands that any information provided to the Lawyer is confidential to the full extent permitted by the law and required by the Missouri Rules of Professional Conduct. Client understands that information provided at the clinic may be reviewed by and shared with other members of Legal Aid of Western Missouri.
6. Client Records. Lawyer and Client understand that Legal Aid of Western Missouri can destroy documents provided by Client seven years after today’s date. Client has been given a copy of this form to keep for his/her records.
The UMKC LAWMO Self-Help Law Clinic offers limited scope representation. This means a volunteer attorney will assist you during your meeting (whether by phone, email, or web service). After that, it is your responsibility to proceed with your case on your own.

Please indicate if you understand this?   Yes   No*

The UMKC-LAWMO Self-help Law Clinic is designed to provide information and resources for those seeking help to represent themselves in the State of Missouri. Any advice, information and forms provided to you by
the Clinic are based on the information you have shared about your legal issue. Forms provided are not intended to take the place of legal advice. You will have the opportunity, if you choose, to talk to a volunteer attorney and receive legal advice. If you choose not to talk to an attorney, you may permanently lose important legal rights and claims.
If, after discussing your case with a volunteer attorney, you are interested in further legal assistance or representation for your claim, the Missouri Bar maintains a “Lawyer Search” page where you can find a
list of private attorneys. The Missouri Bar’s website: https://mobar.org/public/LawyerSearch.aspx.

Please indicate if you understand this?    Yes   No*

Client understands and fully agrees to all of the terms and conditions of this agreement, including those relating to the limited scope of the Lawyer’s representation of Client.

Date: Date*

Signature: Signature*

Initial Consultation
Reviewed by

First Name Last Name
Reviewer Email
example@example.com
Review Date

Month Day Year
Date
Initial Assessment
Forms

Cancel of
Interview Scheduled

Month Day Year
Date
Hour Minutes AM/PM Option
Zoom Meeting Link

Attorney's Information
Attorney's Information
Attorney's Name

First Name Last Name
Attorney's Email
example@example.com
Attorney provided information and/or advice regarding:
Activity Type

Counseled client Provided forms Completed documents Reviewed documents Legal research/provided opinion Other
Outcome
Upload any completed form(s)

Cancel of
Attorney's signature

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Date

Month Day Year
Date

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Self-Help Litigant Intake:

Attorney's Information