Consumer Justice Clinic Screening Form - CONFIDENTIAL
1950 University Avenue, Suite 200 Berkeley, CA 94704, p: 510.548.4040 x388, f: 510.849.1536
Today's date is: *
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My full legal name is: *
My primary language is: *
My phone number is: *
It is okay for your clinic to leave me a detailed message at this number:
Clear selection
My email address is:
It is okay for your clinic to send me detailed messages about my legal issue at this email:
Clear selection
I would like to subscribe to the Consumer Justice Clinic email list to receive updates about workshops, events, changes to hours, efforts to change laws, announcements about changes to laws that might affect you, etc.? *
I prefer communication by: *
Am I a current or former EBCLC client? *
Please write a brief description with details of your legal issue, question, and/or goal: *
I have experienced financial or other difficulties because of COVID-19: *
My COVID-19 difficulties include:
My date of birth is (MM/DD/YYYY):
Optional
The city/ state I live in is: *
I am currently living in: *
My household's (all people that live with me that depend on me for support or that I depend on) monthly total combined income before taxes is: *
Total number of individuals live in my household: *
I identify with this gender: *
Optional
I am: *
I identify with this race or races: *
Required
How did you find out about our clinic?
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