Disability Inclusion and Advocacy (DIAL) Clinic

Legal Assistance Intake Form

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Information of the person requiring assistance

First Name * Middle Name Last Name * Date of Birth * Street Address * Unit Number Street Address 2 County City * State * Zip Code * Primary Language Email * Phone Number *

Are you requesting help for another person? Yes No

Case Information

Disability Type * Where did you learn about the Law Clinic? * Why do you need Legal Assistance? Include details about the date(s) of action(s), and the name(s) or title(s) of the person(s) or companies involved *

Is this a time sensitive issue? * Yes No

Why is this a time sensitive issue? When did the Discriminatory Event Occur?

Are you currently represented by a Lawyer? Yes No

Income Race/ National Origin Education Level Gender Identity Children Marital Status

Are you a veteran/active military? Yes No

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Legal Assistance Intake Form

Information of the person requiring assistance

Information of person filing this Form:

Case Information

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