SINGLE MOTHERS OUTREACH INTAKE FORM
Van Nuys Self-Help Legal Access Center
|First Name: | |Middle: | |Last: |
| | | | | |
|Address: |Ethnicity: |
| | |( Asian/Pacific Islander |( White |
|City: State: Zip Code: |( African American |( Other |
| | | | | | |( Hispanic Origin |( Native American |
|Home Phone: | |Date of Birth: | |Do you live in L.A. County? |Sex: |
| | | | |(Yes (No | |( Male (Female |
|Have you ever been served with a | |Do you have an attorney? | |Education: | |Total Monthly |
|restraining order? | | | |( Did not finish High School | |Household Income: |
| | |( Yes | |( High School Graduate/GED | | |
|(Yes | |( No | |( Some College | |$________ |
|(No | | | |( College Graduate | | |
| | | | | | |( NO Income |
|How many in your home?: | |Is this your first visit to the| |What is your primary language? | |How did you hear about |
| | |center? | | | |the Center? |
|Adults_______ | | | |( English ( Spanish | | |
| | |Yes | |( Farsi ( Tagalog | |( Court ( Bar Association |
|Children______ | |No | |( Russian ( Other | |( Legal Aid ( Friend/Family |
| | | | | | |( Other ______________ |
|Why are you visiting the Center? |
|Only Check off 1 box: |
|I have finished filling out the forms and I need them reviewed |I received an eviction. |
|I am here for the class |I want to start an eviction. |
|I want to start a Divorce. |I am being sued because of a car accident. |
|I was given Divorce papers by spouse. |I am being sued because of a credit card bill. |
|My spouse responded to the divorce. |I am being sued because of a medical bill. |
|My spouse did not respond to the divorce and I need to do the next step. |I want a restraining order. |
|My final divorce papers were sent back because something was wrong. | |
|I want to change the child support order I have now. | |
|I want to change the custody and/or visitation order I have now. | |
|I want custody and/or visitation and I am not married to the other parent | |
|( Other:________________________________________________________________________ |
Statement of Understanding
I am asking that the Self Help Legal Access Center help me with information about my case.
Please sign your initials after you read each statement below. I understand that:
• The Center is here to help me help myself. __________(initial here)
• The Center will be giving me legal information. __________(initial here)
• The Center will NOT be giving me legal advice. __________(initial here)
• The Center is available to help both parties. __________(initial here)
• The Center is NOT representing me and this is NOT a private meeting __________(initial here)
I have read and understand the Statement of Understanding written above.
Signature: ______________________________________ Date: ______________________
OFFICE USE ONLY/USO DE OFICINA SOLAMENTE
|Taken care by Paralegal |Vanessa |Norma |Reyna |Diana |
|(circle your name) |Van Nuys |Pomona |Antelope Valley |Back-up |
|Volunteer | |Back-up | |Robby | |Bea | |Sheila | |
|JusticeCorps | | | |Sharie | |Ronnette | | | |
|Check off Type of Assistance Provided: |
|(numbers are for administrative purposes only) |
|DIVORCE | |PATERNITY |
| |32 |Divorce WS 1 | |36 |Paternity WS 1 |
| |32 |Divorce WS 2 | |226 |Paternity Judgment WS |
| |125 |Divorce WS 3 | |36 |Paternity (Non WS) |
| |32 |Divorce (Non WS) | |226 |Paternity Judgment (Non WS) |
| |130 |Divorce Response | |130 |Paternity Response |
| |32 |Divorce Request for Trial Setting | |36 |Paternity Request for Trial Setting |
| |32 |Divorce Default Setting | |36 |Paternity Default Setting |
| |32 |Divorce MSC/Trial Brief | |36 |Paternity MSC/Trial Brief |
| |126 |Divorce Judgment (Non WS) | |131 |Order to Show Cause Initial – Paternity |
| |127 |Order to Show Cause Initial – Divorce | |131 |Order to Show Cause Mod - Paternity |
| |127 |Order to Show Cause Mod - Divorce | |131 |Order After Hearing |
| |127 |Order After Hearing | | |
| |31 |Joint Petition for Summary Dissolution | | | |
|OTHER FAMILY LAW | |NON-FAMILY LAW |
| |33 |Guardianship | | |225 |Starting an Eviction |
| |34 |Name Change Adult | | |63 |Answer to Unlawful Detainer |
| |34 |Name Change Child | | |102 |Civil Harassment |
| | | | | |03 |Contract Answer |
|OTHER | | |94 |Auto Accident Answer |
| |99 |Other | |
|Level of Service: | | | | |
|Scheduled for Workshop |Assisted at Workshop |Individual Assistance |Gave "How to" and forms only |Referred |
| | |
|Notes: | |
| |
| |
| |
|Referred Litigant to |
|Check off only 1 (the primary referral): |
| | |Legal Services | |Lawyer's Referral |
| | |Family Law Facilitator | |Family Law Conciliator |
| | |Dispute Resolution/Mediation Services | |Consumer Affairs |
| | |Governmental Agency | |Non-Profit Agency |
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