Legal Clinic Prospective Client Form | Governors State University, an Illinois Public University, University Park, IL 60484

First

Last

Age

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Phone

Preferred Communication Language

English

Spanish

Other

Gender Identity

Male

Female

Queer/Non-Binary

Prefer Not To Answer

Other

What is the race/ethnicity you closely identify with?

African American or Black

American Indian or Native American

Asian

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Other

Please select all that apply to you

Military Veteran (active or not active)

Youth (age 17 or younger)

Senior (age 60 or over)

LGBTQ+

Formerly Incarcerated (jail or prison)

An immigrant to the U.S.

Living with a Disability

Impacted by Domestic or Sexual Violence

Do you need reasonable accommodations for your disability/condition? If so, please explain (be as specific as possible - e.g., assistive technology, reader, interpreter)

Household Income

No Income

Under $20,000

$20,000 - $30,000

$31,000 - $40,000

$41,000 - $50,000

$51,000 or more

Area of Concern

Expungement and/or Sealing

Family

Housing

Immigration

Other

Is there a pending case?

Yes

Summary of Dispute

How did you hear about us?