Client Intake Form printable pdf download

– C

EIGHBORHOOD

EGAL

LINIC

LIENT

NTAKE

ORM

Clinic:

Date Seen:

Client: Please complete ONLY the front page of this form.

Name:

Home/Cell Phone:

Street Address:

Work Phone:

City/State/Zip:

Email:

Please read the statement below and initial

Why do you want to see an attorney today?

your understanding.



I understand the Neighborhood Legal Clinics (NLC)

___

program provides advice and consultation only, meaning

the attorney I meet with will not represent me in court or

provide further services.



I understand that NLC attorneys are volunteers and are not

available for hire to represent me.



I understand the NLC attorney may not specialize in the

area of law that I need help with, but will make every

attempt to answer my questions accurately.



I understand that information disclosed to NLC attorneys

and staff is protected by the attorney-client privilege, but

that protection may be limited if I bring other people into

the session.



I understand that I cannot return to the NLC for the same

issue if that issue does not have legal merit.



I understand that the NLC is drug, alcohol, weapon,

violence, aggressive behavior and threat free.

Initials: _______

Permissions

 I give NLC permission to disclose my information for the purpose of referring me for other services.

 I do not give permission to disclose my information for any purpose.

Initials: _______

Past Clinic Visits

Have you visited a Neighborhood Legal Clinic before? Yes  No

If yes, how many times? _____

Have you visited a Neighborhood Legal Clinic before about this same problem? Yes  No If yes, how many times? _________

What happened at your last visit? __________________________________________________________________________________

_____________________________________________________________________________________________________________

What has changed since your last visit? _____________________________________________________________________________

_____________________________________________________________________________________________________________

Statistical Information About You

The information that you provide is used for statistical reports to gain funding for the Neighborhood Legal Clinic Program. Answers to

these questions will not affect the services you receive through the Neighborhood Legal Clinics.

5) Number in household: ___ (

1) Sex:

4) Racial/Ethnic

Include yourself and # of family members living with you)

 Male

Group

6) Monthly Gross Income: $___________ (Combine all monthly income for household

 Female

 Asian

including public assistance - before taxes

 American

Indian/Alaskan Native

2) Date of Birth:

ADMIN USE ONLY

: Clinic Assistants, please circle client’s FPL%

 Black

_____/_____/_____

(Not Hispanic)

 Hispanic/Latino

Household #

Monthly Gross Income

 Middle Eastern

1 →

3) Citizenship

$0 - 487

$488 – 1216

$1217 – 1945

$1946 - 3890

 Native

Status (Optional):

2 →

$0 – 656

$657 – 1639

$1640 – 2622

$2623 – 5244

 US Citizen

Hawaiian/Pacific

3 →

$0 - 825

$826 – 2061

$2062 – 3298

$3299 – 6596

 Non-Citizen

Islander

4 →

$0 – 994

$995 – 2484

$2485 -3975

$3976 – 7950

 White

Status:_________

(Not Hispanic)

5 →

$0 – 1163

$1164- 2907

$2908 – 4652

$4653 – 9304

 I decline to answer

 Other

6 →

$0 - 1332

$1333- 3330

$3331 - 5328

$5329- 10656

FPL

0-50%

51-125%

126-200%

201-400%



Client’s income is more than the highest amount listed on this chart

Client Intake Form

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