Family Intake and Consent Form

Dade Legal Aid

For Initial Filing of a Divorce with minor children, Paternity or Custody.
*NOTE - PLEASE READ BEFORE COMPLETING THIS APPLICATION.
DADE LEGAL AID'S FAMILY DEPARTMENT OFFERS LEGAL SERVICES TO:
- Miami-Dade County Residents (Must be living in Miami-Dade County for more than 6 months)
- Low-income individuals
- Your case MUST be an Initial Filing or you have been recently served:
  For a Custody case – Your minor children must live with you
  For a Divorce case - your minor children must live with you
  For a Paternity case – your minor children must live with you
OR
- You have been served with a Custody, Divorce or Paternity and have ONLY filed a response
*We don't handle any modifications, reopening of cases or Post Judgement matters

For more information please contact the Receptionist at 305-579-5733 x 2222
Today's Date*

MonthDayYear
Date
Please Select if you are requesting...*

DivorceCustodyPaternity
Full Name*

PrefixFirst NameMiddle NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState

Zip Code
City*
You Must be a Resident of Miami-Dade County
Home Phone Number*
Cell Phone Number*
E-mail*
example@example.com
Social Security #
Date of Birth*

MonthDayYear
Country of Birth*
Do you speak English? If no, please select from below.

YesNo
Language Spoken*

CreoleEnglishFrenchGermanHebrewItalianPortugueseRussianSpanishOther
Language Spoken

CreoleEnglishFrenchGermanHebrewItalianPortugueseRussianSpanish
Referred by:

Source of Income / Fuente de ingreso*

	Select	Frequency	$ Amount
AFDC/Other Welfare
Alimony
Child Support
Employment
Food Stamps/Commodities
Household Member Employment
No Income
Other
Pension/Retirement (Not Soc. Sec.)
Social Security Disability
Social Security Retirement
Spouse
SSI
TANF
Unemployment Compensation
Veterans Benefits
Workers Compensation

Source of Income
Amount per Month: $
Total # in Household*
Number of people under 18 in your household*
Number of people 18 and over in your household*
Please select if your request for legal services is related to issues caused by the COVID-19 pandemic.

YesNo
Ethnicity*

Asian AmericanAfrican AmericanHispanicNative AmericanPacific IslanderWhiteOther
Marital*

DivorcedMarriedSeparatedSingleWidowWidower
Education*

High School GraduateCollege GraduateGraduate SchoolUnknownLast Grade Completed
Employment*

Full timePart TimeRetiredUnemployed
Are you/ Have you:*

A VeteranOther PartyIn BankruptcyOther PartyIn ForeclosureOther PartyOwn a BusinessOther PartyOwn Real EstateOther PartyFiled for DivorceOther PartyFiled a Restraining OrderOther Party
Citizen Status*

I am a US CitizenI am a Resident (Green Card)No Status
If you-or the other party have filed for or answered any court proceeding in family court please provide:
Case #:
Self HelpPrevious Attorney
Previous Attorney
Case #:
Self HelpPrevious Attorney
Previous Attorney
Other Party's Information
Name (Spouse or Parent of Child)*

First NameMiddle NameLast Name
Previous/Maiden Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Social Security
Date of Birth

MonthDayYear
Date
Source of Income
Amount per Month: $
Briefly explain your problem and what you would like Legal Aid to do for you
Name of Minor Children with the Other Party
Do you have children with the other party?*

YesNo
Child 1
Date of Birth

MonthDayYear
Date
Child lives with Mother Father or Other

MotherFatherOther
Child 2
Date of Birth

MonthDayYear
Date
Child lives with Mother Father or Other

MotherFatherOther
Child 3
Date of Birth

MonthDayYear
Date
Child lives with Mother Father or Other

MotherFatherOther
I have read the below and agree and understand the following:

Based upon the information I have provided I may qualify to receive free legal services. If my case is initially accepted and I am referred to a staff attorney for a further intake appointment, the attorney will gather additional information necessary for the final review of eligibility.

I agree and understand that until I have met with the attorney and Legal Aid has accepted my case, Legal Aid does not represent me, will not make any appearances on my behalf, and does not take any responsibility for my case.

I understand and agree that if I fail to appear for the intake with an attorney, or do not provide necessary documents for my case, my file will be closed with this office, and I must reapply if I decide to proceed in the future.
Please Sign*

Clear
In accordance with the Americans with Disabilities Act of 1990, persons needing a special accommodation should contact the ADA Coordinator, Eileen Coto, 305-579-5733x2240, ecoto@dadelegalaid.org; If hearing impaired you may call the Florida Relay Service telephone number, 1-800-955-8771 for assistance.
Should be Empty:

Dade Legal Aid

*NOTE - PLEASE READ BEFORE COMPLETING THIS APPLICATION.

If you-or the other party have filed for or answered any court proceeding in family court please provide:

Other Party's Information

Name of Minor Children with the Other Party