Snohomish County Legal Services Client Intake

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Please complete and submit this intake within 7 days so that we may determine your eligibility for services.. After we receive the completed intake, we will contact you regarding an appointment. If we do not hear from you within 7 days, we will assume that you are not interested in using our services. Please note - completing this intake does not establish an attorney-client relationship and does not guarantee you services. ALL ANSWERS ARE STRICTLY CONFIDENTIAL.

Last Name *

First and Middle Name *

Are you getting ready to file for Divorce in Snohomish County? *

Yes

Are you getting ready to finalize a Divorce in Snohomish County? *

Yes

Has there been Domestic Violence between you and the Opposing Party? *

Yes

How have you been affected by COVID-19? (check all that apply) *

Loss of job or income (temporary or permanent)

Increased expenses from staying home (ie, paying for delivery of food/ household items)

Increased stress from staying home (ie, creating family tension/fighting, depression)

COVID-19 didn't really affect my life much

Other:

Required

Will you be willing and able to meet with an attorney with videoconference (Zoom or GoogleMeet)? *

Yes, Zoom

Yes, GoogleMeet

Either

Who referred you to our services? How did you hear about us? *

Gender *

Female

Male

Transgender

Non Binary

Prefer Not to Answer

Other:

Birthdate *

YYYY

Age *

Do you reside in Snohomish County? *

Yes

Other:

Street Address (where you actually live) *

City, State *

Zip Code *

Living Situation? *

Rent

Own

Homeless

Mobile Home

Foreclosure

Hotel/Motel

Living with a family member

Living with a friend

Transitional housing

Emergency shelter

Other:

Does your legal matter affect the stability of your housing situation? *

Yes

Maybe

Other:

Preferred Phone number *

Mobile Phone number *

Can we leave Voicemails at this number? *

Yes

Are you willing to receive texts? *

Yes

Home Phone number

Email Address *

What is your primary language? *

English

Spanish

French

Russian

Chinese

Japanese

Tagalog

Amharic

Somali

Other:

Do you require or would you like to request an interpreter? *

Yes

Client Ethnicity *

Hispanic/Latino/a

Not Hispanic/Latino/a

Prefer not to answer

Client Race *

Black or African American

Latino/a

White

American Indian or Alaska Native

Arab or Middle Eastern

Asian

Native Hawaiian or Pacific Islander

Multi-race

Prefer not to answer

Other:

Highest Level of Education? *

0-8 grade

9-12 grade (non-graduate)

HS grad/GED

12+ post secondary

2-4 year college graduate

Health Insurance Status? *

Uninsured

Medicaid

Medicare

Private Insurance

Other:

Are you a Veteran? *

Yes

Are you disabled? *

Yes

Prefer not to disclose

Other:

Citizenship status? *

U.S. Citizen

Lawful Permanent Resident

Undocumented Alien

Asylee

Refugee

Other:

Family Type: Family living with you that you are financially responsible for. (If you are currently living with your spouse and trying to separate, please select 'other' and explain) *

Single Parent Female

Single Parent Male

Two-Parent Household

Single Person

Two Adults - No Children

Other:

Family Size: How many Adults live with you that are in a personal relationship with you (i.e. domestic partner - do not list roommates) *

Please list the full names of the other adults that are part of your financial household. *

Family Size: How many children do you have that are still financially dependent on you? *

Children's Ages *

How many of your own children live primarily with you? *

What is your GROSS monthly income? (Income before taxes are taken out) (INCLUDE THE INCOME OF ANY DOMESTIC PARTNERS THAT RESIDE WITH YOU) *

What is the source of that income? (CHECK ALL THAT APPLY) *

No income

Employment

SSI

Social Security/SSDI

General Assistance

Pension

Unemployment

Employment + Other Sources

TANF

Child Support

Spousal support or monthly payments made on your behalf by spouse

FOOD STAMPS

Other:

Required

Please enter the gross amount of EACH source of income, including food assistance. *

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