Confidential Appointment Request Form - Jane Doe Legal Clinic

Client Information

First Name

Middle Name

Last Name

Preferred Pronouns

Date of Birth

Email Address

Phone Number

Street Address

City / Province / Postal Code

Special Contact Instructions

Any privacy concerns about contacting you?

Do you require an interpreter? If yes, which language?

Do you have accessibility needs?

Household & Income

Approximate monthly income after tax

Number of dependents (and relationship)

Self-Identification (Optional)

IndigenousBlackRacialized personImmigrant or refugeePerson with a disabilitySex workerLGBTQ2S+

Other

Opposing Party Information

Full Name (and aliases)

Date of Birth

Email Address

Phone Number

Legal Matter Details

Type of legal issue

Upcoming court hearing or appearance details

Brief description of the issue

Are there any safety or violence concerns?

Do you currently have a lawyer?
YesNo

Have you applied for Legal Aid?
YesNo

How did you hear about Jane Doe Legal Clinic?

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Upload Supporting Documents (Optional)

Your Message