NQAPIA Legal Referral: Legal Intake Form
NQAPIA’s legal referral program will put you in touch with an attorney who may be able to assist you, provide legal advice, answer legal questions, and potentially represent you in a particular matter. NQAPIA makes no guarantee we will be able to find an attorney for you or that we can provide representation. NQAPIA does not take on legal cases ourselves, but our staff lawyers will do our best to provide competent referrals.

Please complete the following.

All information will be kept strictly confidential and in the custody of attorneys.

Contact Information
If you need legal services, please fill out this section with your information. If you are filling this out on behalf of someone else, write their information here.
Preferred Name
Your answer
First Name *
Your answer
Last Name *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Some legal services are free depending on your financial status.
Is your household’s combined annual income below $31,000? *
Legal Problem/Question
Please give as much information as possible about your situation or question stating facts, dates, times, location, names of other parties, any notices received. More detailed information will help NQAPIA reach out to lawyers in your area or who are experienced and specialize in the area of law.
Write a description of the legal problem/question.
Your answer
What is the nature of the legal problem/question? Check all that apply.
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