FSJ Service Request Form

Is this a request for legal services or to report an incident?*

Legal servicesIncident report
Service Request Form

If you would like support in submitting a service request, please call or text FreeState staff at (443) 977- 4254.
Date

YearMonthDay
FreeState Justice provides legal services, referrals, and resources to lesbian, gay, bisexual, transgender, and queer Maryland residents that qualify based on income. These services may be provided by FreeState Justice staff or by a member of our pro bono attorney network.

Legal Services--FreeState Justice intake is now open for the following legal matters:
- Name Change
- Gender Marker Change
- Employment Discrimination
- Healthcare & Health Insurance Discrimination
- Advanced Directives & Living Wills
- Public Accommodations or Housing Discrimination
- Criminal Record Expungements
- Family Law (custody, parenting rights, domestic violence, divorce)
- Protective/Peace Order
If you are seeking legal advice or representation regarding one of the above matters, please indicate that this is a request for legal services in the form below. For all other matters, please indicate that this is a request for general advice & resources.

General Questions & Resources--FreeState Justice is supporting the following referrals:
- Housing services
- Healthcare services (Physical, Behavorial, and Mental Health)
- Government Asssistance Applications (SNAAP, WIC, etc.)
If you are seeking resources regarding one of the above matters, please indicate that this is a request for general advice & resources in the form below.

Incident Reports--FreeState Justice is supporting anti-LGBTQ incident reports for the following:
- Civil rights complaints
- Community violence incident report
- Police interactions
- State agency interactions (DSS, DHS, DJS, etc.)
- Discrimination in education (K-12, Higher Education)
- Government services discrimination
If you are seeking resources regarding one of the above matters, please indicate that this is a request for general advice & resources in the form below.

If you have questions regarding a request for legal services please call: (443) 977- 4254 or questions regarding obtaining resources please call: (443) 977- 4243.

*** Remember to add the domain @freestate-justice.org to your safe senders list in your email or check your junk folder for our messages! ***

Contact Information

Please provide as much information as possible. If you would like support in submitting a service request, please call or text FreeState staff at (443) 977- 4254.
Are you completing this form for yourself or on behalf of someone else?*
Please select.
Prefix
Prefix or title.
Please fill out the form with the information of the person you are supporting. Please add your name, contact information, and relationship to the person in the Additional Contact section.
First Name*
Chosen name
Middle Name
Optional, chosen name
Last Name
Required only if requesting Legal Services, chosen name
Date of Birth*

MonthDayYear
Pronouns*

they/them/theirsshe/her/hershe/him/hisOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred methods of contact*

EmailPhone callPhone (SMS) textingOther
DoNotCall
DoNotEmail
DoNotText
Phone Number

Area CodePhone Number
Email Address

Confirmation EmailPlease confirm your email address.
Zipcode*
This helps determine eligible services.
County*
This helps determine eligible services .
Do we have permission to contact another person if we cannot reach you?*
If Yes, please provide the contact information for a person we can contact if we are unable to reach you.
Additional Contact Name*
Relationship to additional contact*
Additional Contact Phone Number*

Area CodePhone Number
Additional Contact Email*
example@example.com

Service Request Form

Contact Information

Request for Services

Demographics