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 Pro Bono District F? | ||||
| Have you ever contacted Pro Bono District F before? | ||||
| Gender | ||||
| Date of Birth | ||||
| 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 District 6 Access to Justice, Inc.
Retainer Agreement
"I have requested referral to a private attorney through the District 6 Access to Justice, Inc., pro bono legal aid program for representation.
I understand that eligibility for services does not guarantee a referral by District 6 Access to Justice, Inc., to a pro bono attorney.
If District 6 Access to Justice, Inc., 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 District 6 Access to Justice, Inc., 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 District 6 Access to Justice, Inc., of any change in my household, income, resources, and contact information. I understand and agree that if I become financially ineligible for representation by District 6 Access to Justice, Inc., they may terminate this agreement. Additionally, if I become ineligible for services for any reason specified in federal law or federal regulation, District 6 Access to Justice, Inc., 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 District 6 Access to Justice, Inc., to release records and information pertaining to my case to the pro bono attorney(s)."