New Legal Advocate Program- Intake and Referral Form

Welcome to SASC's Online Intake Services
Thank you for your interest in our Sexual Violence Legal Advocacy Program. If you have any questions or need assistance to complete the form, please reach out to legaladvocate@sascwr.org.

If you are not comfortable answering any of these questions, or do not know the answer, please feel free to skip to the next question.
Referral and Intake Form
Today's Date*

DayMonthYear
Date
I am*

a client seeking servicesa worker making a referral for a client
If you are a worker referring a client:

Before you continue with this form, please make sure that the client has provided their consent for this referral, and for a Legal Advocate from SASC to contact them.
Worker's Name*
Worker's Agency or Organization*
Contact for Worker (Phone or Email)*
Client Information
Client's Name*

First NameLast Name
Client's Date of Birth:

DayMonthYear
Date
Do you require an interpreter?*

YesNo
For what language?*
Client Contact Information
Phone Number*

Area CodePhone Number
Is it safe to leave a message?*

YesNoOther
Email Address
example@example.com
How would you prefer we contact you? Select all that apply.*

PhoneTextEmail
Which city/township are you located in? *

Kitchener or WaterlooCambridge or North DumfriesWellesleyWilmotWoolwichOther
Pronouns (She/Her, He/Him, They/Them, etc.)
Service
What are you looking for support with?*

Reporting to the policeUnderstanding the criminal processUnderstanding civil litigationUnderstanding Restorative Justice processOther
Do you have an urgent need for support within the next 30 days (For example, Police interview, Court dates, Lawyers appointments, etc)? If so, what and when? *
Should be Empty:

Referral and Intake Form

If you are a worker referring a client:

Client Information

Service