Client Intake Form
| Date | ||||
|---|---|---|---|---|
| Name | ||||
| Do you have previous names? | ||||
| Address 1 | ||||
| Address 2 | ||||
| Phone and Best time to call | ||||
| Can you read and write? | ||||
| How long have you lived in Indiana? | ||||
| What is you County of Residence? | ||||
| How long have you lived in the county? | ||||
| How did you hear about Legal Aid of East Central Indiana? | ||||
| Have you ever contacted Legal Aid of East Central Indiana before? | ||||
| Gender | ||||
| Date of Birth | ||||
| SSN | ||||
| Marital Status | ||||
| Years married? | ||||
| Are there children in this relationship? | ||||
| Citizen | ||||
| Disability | ||||
| Pregnant | ||||
| Pending criminal matter? | ||||
| Do you have children? | ||||
| Number of individuals in household | ||||
| How many people do you support? | ||||
| Do you own a home? | ||||
| Do you rent? | ||||
| Income from work: | ||||
| Income from child support: | ||||
| Income from Food Stamps: | ||||
| Income from Soc. Sec. Income: | ||||
| Income from Soc. Sec. Disability: | ||||
| Income from Supplemental Security Income: | ||||
| Income from Temp. Assistance: | ||||
| Income from Other Income: | ||||
| How much cash do you have presently? | ||||
| How much do you have in savings? | ||||
| How much pension do you presently have? | ||||
| What is the value of the vehicle(s) you own? | ||||
| What is the value of the home you own? | ||||
| What is the value of any other realty you own? | ||||
| What is the value of any other property you own? | ||||
| Tax refund? | ||||
| Do you pay child support? | ||||
| Court orders? | ||||
| Opposing Party? | ||||
| Area of need: | ||||
| Narrative |
Applications will not be considered unless accompanied by completing the following Retainer Agreement, Declaration of Citizenship, and Client Authorization and Release for Legal Aid of East Central Indiana.
Retainer Agreement
"I have requested referral to a private attorney through the Legal Aid of East Central Indiana, pro bono legal aid program for representation.
I understand that eligibility for services does not guarantee a referral by Legal Aid of East Central Indiana, to a pro bono attorney.
If Legal Aid of East Central Indiana, makes a referral, I understand that the pro bono attorney will review and evaluate my case and determine whether or not to accept me as a client. I further understand that Legal Aid of East Central Indiana, has absolutely no authority over the pro bono attorney's decision to accept or decline legal assistance. The nature of the services to be provided will be determined by the pro bono attorney on an ongoing basis.
I may terminate this agreement at any time. I understand that I have the responsibility to inform Legal Aid of East Central Indiana, of any change in my household, income, resources, and contact information. I understand and agree that if I become financially ineligible for representation by Legal Aid of East Central Indiana, they may terminate this agreement. Additionally, if I become ineligible for services for any reason specified in federal law or federal regulation, Legal Aid of East Central Indiana, may have to withdraw the referral made to the pro bono attorney."
Declaration of Citizenship
"I hereby declare that I am a citizen of the United States."
Client Authorization and Release
"I authorize Legal Aid of East Central Indiana, to release records and information pertaining to my case to the pro bono attorney(s)."