Legal Assistance Client Intake Questionnaire Form

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Wait Time
Walk-In Number
: Time of App’t _________ Time Arrived _________ Time Intake Form Returned to Clerk _________
For Office Use Only
Time Seen by Atty _________ Case Atty ___________________________ Case Paralegal/LN __________________________
LEGAL ASSISTANCE CLIENT INTAKE QUESTIONNAIRE
FOR OFFICIAL USE ONLY – PRIVACY ACT SENSITIVE. Any misuse or unauthorized disclosure may result in both civil and criminal
penalties.
PRIVACY ACT STATEMENT: AUTHORITY 5 U.S.C. 301 & 44 U.S.C. 3101 DoD ID NUMBER PRINCIPAL PURPOSE(S): Information is to
monitor the caseloads in legal assistance office. ROUTINE USE (S): Information provided is used to assign cases and monitor legal assistance
attorneys and assigned clerical personnel.
MANDATORY/VOLUNTARY DISCLOSURE, CONSEQUENCES OF REFUSAL TO DISCLOSE: Disclosure of DoD ID Number is voluntary and there will
be no adverse consequence from refusal to disclose; however, an individual may be requested to establish eligibility for legal assistance by other
means (e.g., production of military identification). Refusal to establish eligibility may preclude the requested assistance. Disclosure of all other
requested information is voluntary, but failure to provide such information may limit this Command’s ability to provide assistance.
1. Your Name (Last, First, Middle):
2. DoD ID Number (if known):
3. Gender: (circle)
4. Date of Birth:
5. Eligibility: (circle)
Office Staff: Reference JAGMAN Ch. 7 for details on legal assistance
eligibility and consult with your supervisor
M
F
DD_____ MMM_______ YYYY_______
Active Duty
Dependent of Active Duty Member
6. Service Branch of Yourself or Sponsor: (circle one)
Retiree
Dependent of Retiree
Reservist (inactive/drilling)
Dependent of DOD Civilian
(overseas only)
USN
USA
USAF
USCG
USMC
DOD
20/20/20 Spouse
DOD Contractor
(overseas only)
DOD Civilian
7. End of Active Duty Service Obligation:
8. Pay Grade:
9. Rank/Rate:
DD________ MMM__________ YYYY__________
10a. Command:
10b. Deploying?
If yes, estimated date:
 Yes
 No
DD______MMM______YYYY______
11. YOUR Current Home or Mailing Address:
City:
State:
Zip:
12a. Home Telephone: (_________)____________________
12b. Cellular: (_________)___________________________________
12c. Work: (
)
13a. Email Address:
14a. Spouse’s Name (Last, First, Middle):
14c. Spouse’s Maiden Name:
14b. DoD ID Number (if known):
 Yes
 No
15. Have you hired a civilian attorney relating to the legal issue(s) to be discussed today?
 Yes
 No
16. Have you previously met with any military attorney relating to the legal issue(s) to be discussed
today?
 Yes
 No
17. Are you seeking services relating to a pending Civilian Administrative Forum?
(OCONUS only)
 Yes
 No
18. Are you seeking services because you are a victim of a crime?
 Yes
 No
19. Are you seeking services because you are a victim of domestic violence or assault of any kind
involving a service member?
20. PROVIDE INFORMATION ABOUT THE PERSON/BUSINESS WITH WHOM YOU HAVE A LEGAL DISPUTE/ISSUE
For divorce/child custody and support/paternity issues, it’s your spouse/the other parent. For housing issues, it’s usually the
landlord. For consumer fraud/abuse and identity theft, it’s the person/company committing the fraud/abuse/theft, etc.
Full Name: (Last, First, Middle)
(Maiden, if applicable)
Date of Birth, if known:
DD_____ MMM_______ YYYY_______
Military:  Yes  No
Address:
21. What issues will you be discussing during your appointment?
***Please turn this form over and check all applicable legal categories in the client use boxes. ***
Your Signature _____________________________________
Date__________________
For Office Use Only
: ID CARD SCREEN ______ INITIAL CONFLICT CHECK ______ ATTY CONFLICT CHECK ______
FILE CREATED ______ CL & OP ENTERED INTO CMTIS ______ SERVICES ENTERED INTO CMTIS ______
Revised Sept 2014
Mandatory Use/OJAG Code 16

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