Teamwork Englewood Legal Clinic Screening Form
Are you currently a U.S. Citizen? (If not, you should consult an immigration attorney before proceeding):
Please Select
Yes
No
Name
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When was the last time you were arrested? (month/year)
Have you ever spoken to another attorney or legal aid organization about this legal issue?
Please Select
Yes
No
If YES, please list the organization.
Are you currently serving a sentence for a criminal offense, including probation, parole, or court supervision?
Yes
No
When will you be released ? (month/year)
Have you ever served a sentence for a criminal offense, including probation, parole, or court supervision?
Please Select
Yes
No
If YES, please include the month and year you were released from this sentence:
Do you have any pending cases ?
Yes
No
Have you previously had a felony conviction sealed?
Yes
No
While serving your last sentence, aftercare release, or mandatory supervised release, did you receive any of the following? (Note: If you were never sentenced, select “none of the above.”)
High School Diploma
Associate's Degree
Career Certificate
Vocational Technical Certification
Bachelor's Degree
GED
None of the Above
Gender
Male
Female
Non Binary
Transgender
Other
Race/Ethnicity
Black
White
Latino
Asian
Alaska Native or American Indian
Native Hawaiian or other Pacific Islander
Other
Were You Referred to us by another organization?
Yes
No
Who Referred You
Please Select
Cabrini Green Legal Aid
Legal Aid Chicago
CARPLS
TREAD
Chicago Urban League
SEIU
Warehouse Workers for Justice
G.O.D (Giving Others Dreams)
IMAN (Inner City Muslim Action Network)
Other
Please upload a copy of your RAP Sheet (if available)
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Signature
Date
/
Month
/
Day
Year
Date
Services Requested
Legal Referral
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