Legal Aid/Assistance Intake Referral Form

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If you or someone that you know needs Legal Aid or Assistance, PLEASE copy and paste the completed form in the comments section below so that we can determine the best way to assist them.

This form is provided with the understanding that A&MWF is not rendering legal, accounting, or other professional advice or service. Professional advice on specific issues should be sought from an accountant, lawyer, or other professional.

LEGAL AID INTAKE REFERRAL FORM

Please note that this information has been gathered to help us provide Your Client with a service that will meet thier needs. The information will be treated in STRICT CONFIDENCE.

Name of Applicant(required)

Your Email Address (required)

What is the Subject of your inquiry

How can we help you

Best Contact Information For Applicant(required)

Current Address of Applicant

Phone Number

Age

Date of Birth

Sex

Married, Family. List your dependants, include spouse/defacto/partner/children

Given Name of Applicant

Family Name of Applicant

Does Applicant Use or Has Used Other Names? Please give other name(s)

Is The Aid For A Business, Corporation, Group or Organization

For What Type of Problem Do You Need Legal Aid/Assistance? Family, Criminal, Civil, General

Is The Applicant/Client in Custody or Detention?

What Is The Applicant/Client’s Prisoner Identification Number

When Is The Next Court Date (if you know)?

Have You Applied for Legal Aid/Assistance Before?

Is This Application Being Made for Someone Else?

Name of Referring Person

Contact Information of Referring Person

Why have You Refered Your Client for Legal Aid/Assistance

Where is Your Client Currently Residing

How long Have They Resided There

Are They Moving Out, Why?

Has Your Client Been Registered with Local Social Services, Medical, Housing Authorities? Which Ones?

Do You Speak a Language Other than English at Home?

Were You Born Overseas?

Are You A United States Citizen?

HEALTH HISTORY

Your Client’s Doctor’s Contact Information

Are you aware of any serious physical health problem your client may currently be suffering from or have suffered from in the past? If yes please elaborate.

Has Your Client Ever Suffered from Any Psychiatric illness? If yes please elaborate.

Is Your Client Living with Any Psychiatric illness at present? If yes, please elaborate.

Is Your Client in Contact with Any Support Agency Concerned with Psychiatric illness or with Any Psychiatric Unit? If yes, please give details.

Is Your Client on Any Type of Medication? If yes, please give details.

Does Your Client have Any Learning Difficulties? If yes, please elaborate.

Have these difficulties been formally identified through the health board disability services? If Yes please elaborate

PATTERNS OF BEHAVIOUR

Has Your Client Ever Been the Victim of Violence? If yes, please elaborate.

Has Your Client Ever Had an Addiction Problem? If yes, what form(s) has this taken?

Is Your Client Currently Drinking, Using Unprescribed Drugs, or Gambling? If yes, please elaborate.

Has Your Client had Contact with Any Addiction Support Service? If yes, please elaborate.

Has Your Client Had a Criminal Conviction? If yes, please elaborate.

Has Your Client Had Any Involvement with the Probation Service? If yes, please elaborate.

Has Your Client Ever Attempted to Inflict Serious Self Harm? If yes, please elaborate.

Does Your Client Have Any Behavioural Problems? If yes, please elaborate.

Is Your Client Receiving Any Support / Assistance from Any Services for These Problems? If yes, please elaborate.

CLIENT’S FINANCIAL SITUATION

What is Your Cient’s Main Source of Subsistence? Employment, Unemployment Assistance/Benefit, Sickness Benefit, Disability Allowance, Pension, Job Training Allowance, Grant, Other

If Your Client is On a Pension or Grant or Another Source of Subsistence, please state It’s Source, the Amount, Method and When It’s Paid.

What is The Main Source of Income of Anyone Financially Associated with Your Cient. Do they Receive Employment, Unemployment Assistance/Benefit, Sickness Benefit, Disability Allowance, Pension, Job Training Allowance, Grant, Other

Does Your Client, Anyone Financially Associated with Your Cient or Any Dependant Children Receive Employment, Unemployment Assistance/Benefit, Sickness Benefit, Disability Allowance, Pension, Job Training Allowance, Grant, A Partner in a Business, A Director/Shareholder in a Business or Company, Receiving Money From a Trust, Receiving Any benefit from a Business or Company? For example, use of a Car, Telephone, Payment of School Fees, Other

Does Your Client, Anyone Financially Associated with Your Cient, or Any Dependant Children make Housing Payments, Mortage, Rent, Board on Your Client’s Behalf and How Much?

Does Your Client, Anyone Financially Associated with Your Cient, or Any Dependant Children Pay Any of the Following Expenses Each Week on Your Client’s Behalf? Child Care , Spousal Support, Loans, Other debts.Give details

Does Your Client, Anyone Financially Associated with Your Cient, or Any Dependant Children Own a Home or Any Other Real Estate? Give financial details

Does Your Client, Anyone Financially Associated with Your Cient, or Any Dependant Children Own Any Motor Vehicles, Including Vehicles You are Paying Off and Other Person’s Vehicles. Give details of Your Vehicles Year , Model, Market Value, Money Owing.

Does Your Client, Anyone Financially Associated with Your Cient, or Any Dependant Children have any Financial Accounts with a Bank, Financial Instution, Credit Union, have Financial Instruments, Cash or Money Invested with Other Persons? Give Details of Accounts

Does Your Client, Anyone Financially Associated with Your Cient, or Any Dependant Children Own Anything Else of Value? For example, Shares of Stock, Bonds, Boats, Precious Metals, Jewellery, Insurance, Etc.? Give Details of Accounts

Has Your Client, Anyone Financially Associated with Your Cient, or Any Dependant Children Sold or Given Away any Money or Property Worth More Than $500? Give Details.

Did Your Client, Anyone Financially Associated with Your Cient, or Any Dependant Children Get Any Lump Sum Amount(s) of Money Greater than $500 in The Last 12 months? For example, a Loan, Gift, Compensation, Award from a Court Case, etc.? Give Details.

Does Your Client, Anyone Financially Associated with Your Cient, or Any Dependant Children Expected to Get Any Lump Sum Amount(s) of Money in the next 12 months? Like a loan, gift, Compensation, Award from a Court Case, etc.? Give Details.

Has Your Client, Anyone Financially Associated with Your Cient, or Any Dependant Children Paid Any of Your Legal Fees for This Case? Can/ Will They Pay Any Fees? Give Details.

Briefly Explain Your Legal Problem— Please Attach Copies of Any Documents, Summonses or Charge Sheets Relating to This Matter. Do Not Give Originals and Provide Details.

For Criminal Matters—What Offences are Your Client Charged With? Give Details.

For All Other Matters— Give Details.

What and Where is the Court and Provide Case Number, Judge?— Give Details.

Has Your Client Had an Attorney In This Case? Who Do They Want as Their Lawyer? In Some Cases, You May Not Get the lawyer you Choose. Want A Legal Aid lawyer, A Private Lawyer?— Give Details.

FAMILY LAW ONLY

Provide Details of The Person(s) Your Client Is In Dispute With. Their Full Name, Date of Birth, Address, Phone Number, Their lawyer’s Name, Lawyer’s Address

Was Your Client Married to The Person They are in Dispute With? Give Date of Marriage, Date of Separation, Date of divorce

Has Your Client Been to Counselling/Mediation? Give Details

Is There Existing Court Orders in Relation to This Dispute? Give Details

CRIMINAL LAW ONLY

Was Anyone Else Charged with Your Client for These Offences? Give Details

Is Your Client Committed for Trial? Give Details

Does Your Client Have Any Prior Convictions? Give Details

CIVIL OR GENERAL LAW ONLY

Please Give The Date and Place where Your Clients Accident or Problem Happened.

Who is Your Client in Dispute With? Please Give Details if Known

Is Your Client Insured Against Any Part of This Claim/Loss? Give Policy Information, Name and Address of Insurer

What Is Your Client ‘s Estimate The Amount of The Claim/Loss

OTHER INFORMATION

Is There Any Other Information That You Would Like to Offer?

Give Us Your Self Assessment of The Situation

Please note that this information has been gathered to help us provide Your Client with a service that will meet thier needs. They should not fail to provide information required of them and which is relevant to this application for legal aid/assistance. They MUST provide all documents to us in connection with this application for legal aid/assistance and it is a crime to present information that is false or misleading and they MUST NOT make a false or misleading statement either orally or in writing in relation to this application for legal aid/assistance and therefore declare that all the information they have given is true and correct. The information will be treated in STRICT CONFIDENCE.
I Accept the Aaron and Margaret Wallace Foundation’s Terms of Submission.

Legal Information & Assistance

Ask a Lawyer

Drop-in legal information for tenants twice a month at OHA.

Click here to view the schedule

Bay Area Legal Aid

405 14th Street, 11th floor

Oakland, CA 94612

(510) 663-4744

(800) 551-5554

www.baylegal.org

Centro Legal de la Raza

1001 Fruitvale Avenue, Second Floor

Oakland, CA 94601

Spanish – (510) 437-1554

English – (510) 437-1554 and press 2 #

http://www.centrolegal.org/

East Bay Community Law Center

3130 Shattuck Avenue

Berkeley, CA 94705

(510) 548-4040

www.ebclc.org

Eviction Defense Center

1611 Telegraph Ave

Oakland, CA 94612

(510) 452-4541

National Housing Law Project

614 Grand Ave., Ste. 320

Oakland, CA 94610

(510) 251-9400

www.nhlp.org

Oakland Rent Arbitration Board

250 Frank H. Ogawa Plaza, 5th Floor

Oakland, CA 94612

(510) 238-3721

http://www.oaklandnet.com/government/hcd/rentboard/index.html

Sentinel Fair Housing

510 16th Street, Ste. 560

Oakland, CA 94612

(510) 836-2687

www.sentinelfairhousing.org

Additional Legal Resources

Alameda County Bar Association

610 16th Street, Ste. 426

Oakland, CA 94612

(510) 893-7160

http://www.acbanet.org

Law Center for Families

510 16th Street, Suite 300

Oakland, CA 94612

(510) 451-9261

www.lcff.org

Lawyers in the Library

Oakland Public Library

(510) 239-3134

http://www.oaklandlibrary.org/services/lawyers.html

Legal Assistance for Seniors

464 7th Street

Oakland, CA 94607

(510) 832-3040

Small Claims Legal Advice Program

661 Washington Street, 2nd Floor (Self Help Center)

Oakland, CA 94607

(510) 268-7665

www.co.alameda.ca.us/courts

Mediation

Trained mediators help landlords and tenants resolve disputes by helping both parties talk through the problem and come to an agreement together.

East Bay Community Mediation

1968 San Pablo Ave

Berkeley, CA 94702

(510) 548-2377

Sentinel Fair Housing

510 16th St., Ste 560

Oakland CA 94612

(510) 836-2687

www.sentinelfairhousing.org

Fair Housing & Discrimination

Bay Area Legal Aid

405 14th Street, 11th floor

Oakland, CA 94612

(510) 663-4744

(800) 551-5554

www.baylegal.org

Housing Rights

P.O. Box 12895

Berkeley 94712

(510) 548-8776

http://www.housingrights.com

Sentinel Fair Housing

510 16th Street, Ste. 560

Oakland, CA 94612

(510) 836-2687

www.sentinelfairhousing.org

U.S. Department of Housing & Urban Development (HUD)

Office of Fair Housing and Equal Opportunity

450 Golden Gate Avenue

San Francisco, CA 94102-3448

(415) 436-8400

(800) 347-3739

TTY (415) 436-6594

www.hud.gov

Fair Housing Information

http://www.hud.gov/offices/fheo/

Housing Discrimination Complaint Line: (800) 669-9777

Disability Resources

AC Transit Paratransit

(510) 817-1717

http://www.actransit.org/riderinfo/paratransit.wu

Access Improvement Program

City of Oakland grants for accessibility modifications in rental housing

Residential Lending & Rehabilitation Services

(510) 238-3909

www.oaklandnet.com/government/hcd/loansgrants/access_rent.html

Center for Independent Living (CIL)

2539 Telegraph Ave

Berkeley, CA 94704

(510) 841-4776

TDD: (510) 848-3101

www.cilberkeley.org

CIL Field Offices:

Oakland Office

610 16th Street, 4th Floor

Oakland, CA 94612

(510) 763-9999

TDD: (510) 444-1837

Fruitvale Satellite Office:

Centro de Vida Independiente CIV

Spanish Speaking Citizens Foundation

1470 Fruitvale Avenue

Oakland, CA 94601

(510) 536-2271

East Oakland Office:

7200 Bancroft Ave, Suite 9 A

Oakland, California

(510) 635-4920

Disability Rights Education & Defense Fund

2212 Sixth Street

Berkeley, CA 94710

(510) 644-2555 V/TTY

www.dredf.org

Housing Consortium of the East Bay

(for people with developmental disabilities)

1736 Franklin Street, 6th Floor

Oakland, CA 94612

(510) 832-1315

www.hceb.org

Housing Rights

P.O. Box 12895

Berkeley 94712

(510) 548-8776

www.housingrights.com

Protection & Advocacy Incorporated

433 Hegenberger Road, Suite 220

Oakland, CA 94621

(800) 776-5746 Voice/TDD/TTY

www.pai-ca.org

U.S. Department of Veterans Affairs

www.va.gov

Online government disability resources:

Federal disability resource page:

www.disabilityinfo.gov

Americans with Disabilities (ADA) Homepage

http://www.usdoj.gov/crt/ada/adahom1.htm

Senior Resources

Adult Day Services Network of Alameda County

7751 Edgewater Drive

Oakland, CA 94601

(510) 883-0874

www.adsnac.org

AC Transit Paratransit

(510) 817-1717

http://www.actransit.org/riderinfo/paratransit.wu

Alameda County Adult & Aging Services

Eastmont Town Center

6955 Foothill Blvd, Suite 300

Oakland, Ca 94606

(510) 577-1900

http://www.alamedasocialservices.org/public/about/departments/

adult_and_aging/index.cfm

Bay Area Community Services

Post Office Box 2269

Oakland, CA 94621-2269

(510) 613-0330

TDD: (510) 613-0328

www.bayareacs.org

Family Bridges, Inc.

168 11th Street

Oakland, CA 94607

(510) 839-2022

www.fambridges.org

Legal Assistance for Seniors

464 – 7th Street

Oakland, CA 94607

(510) 832-3040

Over 60 Health Center/ LifeLong Medical Care

2031 Sixth Street

Berkeley, CA 94710

(510) 704-6010

www.lifelongmedical.org

St. Mary’s Center

635 – 22nd Street

Oakland, CA 94612

(510) 893-4723

www.stmaryscenter.org

The Unity Council

1900 Fruitvale Ave., Suite 2A

Oakland, CA 94601

(510) 535-6900

(510) 534-7771

www.unitycouncil.org

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