Legal Support Center Intake Form

1
Is this your first time at the Legal Support Center?* This field is required.
Yes, this is my first time.
No, I have been here before and am returning for the same issue.
No, I have been before but am returning for a different issue.
2
Legal First Name* This field is required.
3
Legal Last Name* This field is required.
4
How would you like us to address you?* This field is required.
5
Phone Number* This field is required.
Please enter a valid phone number.
6
Email- If you do not have an email, please put "none at gmail.com"* This field is required.
example@example.com
7
Zip Code- Please use the dropdown to select your full zip code. Be sure the one you select is correct. If you chose the wrong one, you can click the dropdown and select again. * This field is required.
Please Select
Please Select
27214
27233
27235
27249
27260
27261
27262
27263
27264
27265
27282
27283
27301
27310
27313
27242
27357
27358
27377
27401
27402
27403
27404
27405
27406
27407
27408
27409
27410
27415
27416
27417
27419
27420
27425
27427
27429
27435
27438
27455
27495
Not listed/Other
8
Your age* This field is required.
Under 18
18-25
26-35
36-45
46-55
56+
9
Your Gender* This field is required.
Male
Female
Transgender
Non-Binary/Non-Conforming
10
Marital Status* This field is required.
Married
Single
Divorced
Widowed
Partnered
11
Your Race* This field is required.
White/Causasian
Black/African American
Hispanic or Latino
Asian
Middle Eastern
Native Hawaiian/Pacific Islander
American Indian or Alaska Native
Other Race
Multi-Racial
12
How many children do you have?* This field is required.
None
1
2
3
4
5 or more
13
Which of the following best describes your personal income last year?* This field is required.
Unemployed
Less than $20,000
$20,001-$40,000
$40,001-$60,000
$60,001-$80,000
More than $80,000
14
Level of Education* This field is required.
Some High School
High School Graduate/GED
Some College
College Graduate
Post Graduate
15
Legal Issue* This field is required.
New Custody/Visitation Complaint-Parent Filing(not emergency)
Non-Parent Custody/Visitation Complaint
Modification of Custody/Visitation
Motion for Contempt (Custody Order Violations)
Absolute Divorce
Eviction (landlord or tenant)
Eviction Appeal to District Court
Modification of Child Support
16
Do you have an existing file number for the issue(s) you are trying to address?* This field is required.Please type in number or None if you don't have one.
17
Do you agree to receive text messages? If you select yes, we may contact you with a request to complete a survey about your experience. We may also contact you about upcoming free legal clinics.* This field is required.
Yes
No
18
Do you agree to receive emails? If you select yes, we may contact you with a request to complete a survey about your experience. We may also contact you about upcoming free legal clinics.* This field is required.
Yes
No
19
How did you hear about us?* This field is required.
Clerk's Office
Family Justice Center
Legal Aid
Child Support
Judicial Staff
Attorney
Friend/Family
Google/Website
News/Newspaper
Social Media
Community Provider
Should be Empty: