LSNC Name/Gender Marker Change Appointment

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By completing this form, you are sending this information to Legal Services of Northern California to screen and schedule the client for an appointment with an attorney to complete the legal name and gender marker change petition.

If you prefer phone assistance, please call us at 888-354-4474 instead of filling out this form.

The client gives permission to Legal Services of Northern California to contact them to screen and schedule them for a name/gender marker change appointment.

[El cliente da permiso a Los Servicios Legales del Norte de California para comunicarse con ellos para evaluarlos y programarlos para una cita de cambio de nombre/marcador de género.]

Yes (Sí)

Client's name [Nombre del Cliente] *

Email address [Correo Electrónico]

(You will be contacted by email to schedule an appointment. If you prefer phone assistance, please call us at 888-354-4474 instead of filling out this form.)

[El cliente será contactado por correo electrónico para programar una cita. Si prefiere asistencia telefónica, llámenos al 888-354-4474 en lugar de completar este formulario.]

Client's phone number [Número de Teléfono del Cliente] *

Client's date of birth [Fecha de Nacimiento del Cliente] *

YYYY

Client's place of birth (City, State) *

What county does the client live in? [¿En qué condado vive el cliente?] *

Please select one: [Por favor seleccione uno:] *

The client needs help completing the legal paperwork for a name and/or gender marker change petition. [El cliente necesita ayuda para completar la documentación legal para una petición de cambio de nombre y/o género.]

The client has already gotten a court-ordered name/gender marker change and just needs help with changing other ID docs (birth certificate, driver's license, Social Security card, etc.). [El cliente ya obtuvo un cambio de nombre/género ordenado por el tribunal y solo necesita ayuda para cambiar otros documentos de identificación (acta de nacimiento, licencia de conducir, tarjeta de Seguro Social, etc.).]

Other:

Please enter any special notes here (any language needs, disability accommodations, alternate contact info, etc.)

[Ingrese aquí cualquier nota especial (cualquier necesidad de idioma, adaptaciones para discapacitados, información de contacto alternativa, etc.)]

Is the client on any public benefits such as Medi-Cal, CalFresh, CalWORKS, SSI, General Assistance, unemployment, WIC? [¿El cliente recibe algún beneficio público como Medí-Cal, CalFresh, CalWORKS, SSI, Asistencia General, desempleo, WIC?] *

Yes

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