Sunshine Legal Clinic Intake Form
Please fill out the following intake form prior to your legal consultation, If you have any questions or concerns, please contact Charlotte at charlotte@sunshineplace.org or (608) 352-8555.
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First Name *
Middle Name *
Last Name *
Street Address *
City *
Zip Code
What is your phone number? *
If appointment is telephonic, please provide the phone number you would like the attorney to call for the appointment.
What is your email address? *
If you do not have an email address, please answer with N/A.
Family size *
The total number of people living in your household. Please include yourself.
Source(s) of Income (wages, unemployment, social security, public assistance, interest and dividends, worker's comp., etc.) *
What is your total annual family income from all sources (wages, unemployment, social security, public assistance, interest and dividends, worker's comp., etc.) for all members of your family who are at least 18 years of age? *
Date of Birth *
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DD
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YYYY
Head of Household? *
Disabled? *
Race *
Ethnicity *
Gender *
Are you currently in W2? *
W2 is also known as Wisconsin Works or TANF and is a program for low income families and pregnant women.
Please provide a brief overview on the legal assistance you are looking for. *
Generally, what days and times work best for you to speak with an attorney? *
How did you hear about Sunshine Legal Clinic? *
Limited Representation Agreement This is an agreement between Client and Volunteer Attorney, who has agreed to donate his or her time today to assist Client on the matter(s) described on the backside of this Agreement during today’s Sunshine Legal Clinic. SCOPE OF REPRESENTATION The Volunteer Attorney agrees to provide the following services as appropriate to Client at no charge during today’s clinic: Review the facts of Client’s legal matter as presented by Client; Briefly advise Client on legal matter as presented by Client; Assist with determining the steps Client may wish to take to resolve his or her legal matter; Explain legal terms and procedures related to Client’s legal matter; Refer Client to appropriate community or legal resources or information; Identify and assist with appropriate forms needed by Client. ***Please initial below*** *
The Volunteer Attorney WILL NOT provide the following services to Client: Ongoing advice or assistance to Client of any kind in this matter after the conclusion of today’s clinic unless and until both Attorney and Client enter into a separate written representation agreement; Representation of Client in any other case or dispute unless and until both Attorney and Client enter into a separate written agreement; Conduct any independent factual investigation related to Client’s situation; Sign any pleadings on Client’s behalf or contact any other party on Client’s behalf; Any other services not explicitly stated above as a service that Volunteer Attorney will provide. ***Please initial below*** *
CONFIDENTIALITY Attorney and all Sunshine Legal Clinic staff will keep Client’s information confidential but will not keep any copies of Client’s documents. CONFLICTS The signatures of the Volunteer Attorney and Client below acknowledge that (1) neither of them is aware of any conflict of interest that would preclude serving the client under the terms of this agreement and (2) that should evidence of a conflict of interest become known to either the Volunteer Attorney or Client that each agrees to inform the other and take appropriate action, including but not limited to assigning a different clinic attorney to assist the client. ***Please initial below*** *
IMPORTANT INFORMATION Client also understands that Volunteer Attorney will exercise his or her best judgment while performing the limited legal services stated above, but also recognizes: Volunteer Attorney is not promising any particular outcome; Volunteer Attorney has not made any independent investigation of the facts, and is relying entirely on Client’s limited disclosure of the facts given the duration of the limited services provided; Volunteer Attorney has no further obligation to Client after completing the limited legal services described above, unless and until both Volunteer Attorney and Client enter into another written representation agreement. That the Client has the right to retain counsel who might not be subject to the same limitations as the Volunteer Attorney and that it is possible that full representation by an attorney counsel could identify options for resolution of the client’s legal problems that not possible within the service limitations of the Sunshine Legal Clinic. Please initial below: *
I attest that the information provided is true and correct to my knowledge. I understand that the information listed on this form may be subject to verification by Dane County and/or by the U.S. Department of Housing and Urban Development (HUD), the Office of the Inspector General, or their authorized representatives. ***Please initial below*** *
WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. ***Please initial below*** *
Please type your full name in the box below to confirm that you have read all the information in this form. *
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