Legal Assistance Referral Form

Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Legal Assistance - Referral for Services

100 North Laura Street, Suite 600

Jacksonville, Florida 32202

Telephone: (904) 351-0008
Client Contact Information
First Name

First NameMiddle NameLast Name
This is a fill in the blanks field. Please add appropriate blank fields and text.
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Email
example@example.com
Street Address
City
State

Other
Zip Code
Best Time To Contact

Hour Minutes

AM/PM Option
Client DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referring Agency
Release of Information. I hereby authorise a representative of Three Rivers Legal Services to Release information to LISC Jacksonville regarding my contact with Three Rivers Legal Services, the outcome of my case, and the resolution of my referral for services.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Case Manager

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Case Manager Phone
Please enter a valid phone number.Format: (000) 000-0000.
Case Manager Email
example@example.com
LISC ELIGIBLE LEGAL AID NEEDS
SELECT THE LEGAL ISSUES WITH WHICH YOU WOULD LIKE ASSISTANCE

Other
Citizenship Verification
I hereby certify that I am a citizen of the United States of America.
Client Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Client Contact Information