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CLC Referral Request
PLEASE COMPLETE ALL FIELDS BELOW.
PLEASE NOTE: INCOMPLETE/INACCURATE SUBMISSIONS WILL RESULT IN DELAYED RESPONSE TIMES.
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Email
*
Your email
First and Last Name:
*
Your answer
Member's ZIP or Postal Code:
*
Your answer
Member's Email Address:
*
Your answer
Member's Phone Number:
Your answer
Do we have permission to leave a voicemail in the event CLC needs to follow up with the member by phone?
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Yes
No
N/A
Description of the member's situation:
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Your answer
For legal referrals: In what county and state is the member's legal issue?
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Your answer
Will you allow the attorney's office to receive your contact information in the event the attorney needs to reach out to you?
*
Yes
No
Send me a copy of my responses.
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