Clinic Intake Form

Clinic Intake Form

Please complete this form to register for one of our legal clinics. Pre-registration is not required but strongly encouraged to ensure that all clients are seen by an attorney.
Name*

First NameMiddle NameLast Name
Date of the Clinic You Plan to Attend (refer to calendar if needed)*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Apartment Number (if applicable)
Phone Number*
Please enter a valid phone number.
Last Four Digits of your Social Security Number
Email
example@example.com
Race*

African American/ BlackAsianCaucasian/ WhiteHispanicNative American IndianNative Hawaiian/ Other Pacific IslanferOther
Ethnicity*

Hispanic/Latino/SpanishNot Hispanic/Latino/SpanishOther
Birth Date*

MonthDayYear
Gender*

FemaleMaleNon-binary
Primary Language *
Marital Status*
Do you consider yourself homeless?*

YesNo
Do you consider yourself disabled?*

YesNo
Are you in the military or a veteran?*

YesNo
Were you born in the United States, if not where?*

YesNo
Are you a citizen?*

YesNoOther (List any green card, other visa, work permit, victim of crime status, refugee status, etc)
Citizenship Attestation I am a citizen of the United States of America.*

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Victim Status

Victim of Sexual AssaultVictim of Domestic/Dating ViolenceVictim of StalkingVictim of Human TraffickingVictim of Elder AbuseIf you answered yes above, what is your relationship to the offender
For the following put 0 for any household member option that is not applicable to you.

Household Size*

	How many people?
Spouse
Children
Other

Fill out the following fields to the best of your ability

I work and get paid Yes No*
I get paid $How much?*every *
How many hours do you work every week?*

Other forms of income*

	I get $______ money from:
Social Security
Unemployment
Pension/ Retirement
Child Support Received
VA Disability
Food Stamps
Families First/ Other
None of the Above

Expenses*

	My monthly expenses are:
Medical Insurance
Prescription Drugs
Child Care
Rent/ Mortgage
Utilities (water, heat, electricity)
Groceries
Other

If you do not have food stamps, would you like Legal Aid to see if you qualify for them?

YesNo

I have $How Much?* in the bank/cash.
Value of my personal possesions (not car or house) = $How Much* .
I own or am buying my home Yes No*

My home is worth $How Much?.
I owe $How Much? on my home.
I haveNumbercars.
The year/make/model of my car(s) is Type a label .
I owe $ Type a label on my car.

Name of the Person or Company who your legal problem is against (adverse party)*
DOB of person above (if applicable)
Please provide a brief summary of your legal problem (500 character limit)*

0/500

I agree to the conditions listed above

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Should be Empty:

Clinic Intake Form

For the following put 0 for any household member option that is not applicable to you.

Fill out the following fields to the best of your ability