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Personal Information

Intake Date / Time *

Date

Time

Please select today's date and time

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Primary Phone

Cell Phone

Work Phone

Preferred method(s) of contact?

Phone
Email
Text
None, I will contact you

Do you prefer phone or video conference?

Phone
Video Conference
Either

Date of Birth

Active-Duty Military or a Veteran?

Active-Duty
Veteran
Does not apply/Prefer not to answer

Ethnicity

Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer

Race (Check all that apply)

To which gender identity do you most identify?

What is your primary language?

Other Langauge

Do you need an interpreter if English is not your primary language?

Yes
No

Do you have any disabilities which we need to accommodate?

Highest Level of Education

Annual Household Income

(Help us determine your eligibility for certain services and resources)

Primary Source of Income

(Help us determine your eligibility for certain services and resources)

Living Situation

Other Living Situation

Marital Status

Number of people in household (inc. client)

Please enter their name(s), relationship status (ie. spouse, daughter, etc.) and age.

May we contact you after the initial appointment to see if you require further assistance?

Yes
No

How did you hear about us?

Search Engine
Word of mouth
Other

Other

Assistance Information

What can we assist you with?

Can we assist you with legal advice?

Yes
No

Are you in need of the following?

Other

What issues and questions do you want to resolve and answered?

Is there anything you would like us to know about you?

What do you hope to accomplish?

Media Release Agreement

I have read and agree to the Media Release Agreement
I have read and do not agree to the Media Release Agreement

Legal Information

Are you currently represented by an attorney?

Yes
No

Names of attorneys/professionals you have already talked to about this matter?

Names of attorneys/professionals for other parties involved in the dispute?

What, if anything, is your expected outcome with the others involved in this problem?

To enable us to check for potential conflicts of interest, please provide the names of any third parties involved in this matter.

Has there been a legal action filed against you? If so, what type of action, who filed, where and when was it filed?

Is there anything you have done to try to resolve the problem and what was the result?

Will you have children accompany you?

Yes
No

Would you like to have supervised recreation or child care during your consultation with the attorney?

Yes
No

What are their names and ages?

Are there any accommodations that need to be met for the children? If so, please provide details.

Declaration of Eligibility for Pro Bono Legal Aid

I hereby request that PJI provide me with limited assistance in the form of counsel. I certify that I do not have enough money or property to hire a private lawyer. I have provided ShareFair with valid, true, and correct verification of my income.

I understand what this service is considered limited assistance was permitted under the NJ Rules of Professional Conduct 1.2. Because I am unable to afford an attorney, I choose this limited form of assistance as the best alternative available to me.

I acknowledge that I understand the terms of this agreement and have been given an opportunity to ask questions and receive an explanation regarding any part of it that I did not understand.

Signature

Legal Services Agreement

I understand that the purpose of the legal clinic is to provide free legal assistance to low and moderate-income people.

I understand that I will receive a 30–45-minute consultation with a volunteer lawyer regarding my situation.

I understand that I may also be interviewed by a Volunteer Client Advocate before, during or after my legal consultation.

I understand the volunteer lawyer who interviews me will not represent me and has no obligation to provide me with further legal assistance after this appointment.

I understand that I will receive general advice about my legal problem, and that receiving advice is no guarantee of a successful resolution to my legal problem.

I understand that the attorney I meet with may refer me for additional services, such as a legal education, assistance in getting forms or understanding court procedures, or for additional attorney services.

I understand that any information I give my interviewing attorney will be confidential; however, my case may be discussed as needed among PJI staff and volunteer attorneys.I consent to having my general information sent out to attorneys who may be willing to take my case.

I understand that some of the volunteer lawyers may be employed by state and local government. If I am interviewed by a government attorney,

I understand that the attorney who interviews me is acting as a volunteer on his or her personal time and is not acting in his or her capacity as a government employee.

I understand that if I allow another individual (who is not an assistant of the attorney or ShareFair) to sit in on my legal consultation with the attorney, I will jeopardize attorney-client confidentiality. That individual could be called as a witness to testify against me.

I understand that there are often other costs involved in legal proceedings, and that I am responsible for any such
costs.

I understand that the responsibilities of the attorney assisting me are limited to advice and counsel and assistance with drafting or reviewing documents in this meeting and that it is my responsibility to file the pleadings in court, pay the filing fee, and present the case in court.