Legal Clinic Intake Form
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1
2Legal Clinic Intake Form
Veteran Status Confirmed
Child Support consult
CVSO consult
MACV follow up needed
Services provided:
advice
referral
legal forms
other brief service ______________________________________
Atty(s) Initials: ____________________________________________
Intake Worker:
___________________________
Time of Intake: _______________________
___________________________________________________________________________
NAME: First
Middle
Last
PHONE: (
)
EMAIL:______________________________________________________________________
ADDRESS:___________________________________________________________________
____________________________________________________________________________
May we contact you at this phone number and address about your legal issue?
Yes
No
African American Hispanic
Birth date: _______________
Race/Ethnicity:
Asian American/Pacific Islander
Caucasian
Native American
Gender: ____________________
Other: ___________________________
Current living situation:
Homeless – Sign Up for Homeless Provider Screening
Permanent
Permanent Vets Home
VAMC
Transitional
Living with friends/relatives
HUD-VASH
Shelter
Streets
Other
_______________
YES NO
INCOME?
[Does not affect eligibility for services at this clinic]
Employment: ___________________
Amount/mo. __________________
Benefits: _______________________
Amount/mo. __________________
Current VA Case Manager?
Yes
No
Name__________________________________________________
How did you hear about the clinic? ________________________________________________
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Parent category: Business