Legal Clinic Prospective Client Form | Governors State University

First Name:

Last Name:

Age:

City:

State:

Zip Code:

County of Residence:

Email Address:

Phone Number:

Home Address:

Preferred Communication Language:

English
Spanish
Other:

Gender Identity:

Male
Female
Queer/Non-Binary
Prefer Not To Answer

What is the race/ethnicity you closely identify with?

Please select all that apply to you:

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:

Area of Concern:

Is there a pending case?

Yes

No

Summary of Dispute:

How did you hear about us?

First Name:
Last Name:
Age:
City:
State:
Zip Code:
County of Residence:
Email Address:
Phone Number:
Home Address:
Preferred Communication Language: English Spanish Other:
Gender Identity: Male Female Queer/Non-Binary Prefer Not To Answer
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 No
Summary of Dispute:
How did you hear about us?