Community Legal ServicesNorth Shore Family Law Intake Form North Shore Family Law Legal Advocacy Program Intake Form Fill In as Much Information as You Can Today's DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How Did You Hear About Our Services? I am A Previous Client Word Of Mouth NSCR Program Another Organization Other Name of Referring Organization Please Specify How You Heard About Our Services Personal InformationAs Found On Government Issued IDName(Required) First Middle Last Maiden Name (if applicable) Preferred Name (if different than above) Contact InformationHome Address(Required) Street Address City Postal Code How Long Have You Lived at the Above Address Can We Send Mail to This Address?(Required) Yes No Please Provide Alternate Address Email Address(Required) Can We Send Correspondence to This Email?(Required) Yes No Is Your Email Safe and Private?(Required) Yes No Home Phone Number(Required)Cell Phone NumberWork Phone NumberOther Phone NumberIs It Okay to Call You?(Required) Yes No Is Your Voicemail Safe and Private?(Required) Yes No Please Indicate Any Restrictions in Calling You:(Required) Demographic InformationNSCR strives to improve diversity, equity, and inclusion in serving the community. The following questions ask for information about your background that helps us to understand whether underserved individuals and communities are accessing our services.Gender: Male Female Other Please Specify Your Gender Identity Pronouns Date of Birth(Required) MM slash DD slash YYYY Place of Birth Were You Born in British Columbia? Yes No What Date Did You Start Residing in British Columbia MM slash DD slash YYYY Marital Status(Required) Single Married Divorced Separated Widowed Common Law Household SizePlease enter a number greater than or equal to 1.Age of Child(ren) (If Dependents) My Race/Ethnicity Is: Primary Languages Spoken: Languages Spoken, Other than Primary Langauge: Do You Require Translation? Yes No Will Someone Accompany You to Assist with Interpretation or Translation? Yes No Do You Self Identify as Indigenous Yes No With Which of These Do You Self Identify As? First Nations Métis Inuit Employment / Income / Expenses InformationSource of Income:(Required) Employed Social Assistance (Welfare, PPMD, PW) Employment Insurance Pension (Not CPP) Canada Pension Plan (CPP) Other Please Specify Source of Income: Gross Annual Household Income:(Required)Gross Annual Personal Income:(Required)Employer: Job Title: Length of Employment: Opposing Party InformationLegal Name(s) of the Opposing Party(Required) First Middle Last Maiden Name (if applicable) Preferred Name (if different than above) Gender: Male Female Other Were They Born in British Columbia Yes No What Date Did They Start Residing in British Columbia MM slash DD slash YYYY Home Address Street Address City Postal Code Email Address Home Phone NumberCell Phone NumberOpposing Party's Employer: Opposing Party's Job Title: Opposing Party's Gross Annual Income:Opposing Party's Length of Employment: Are There Any Mental Health, Drug, or Alcohol Concerns? Type of Case and Legal InformationPlease Indicate the Type of Family Law Issues You Are Seeking Assistance With:(Required) Divorce Separation Child Support Parenting Time Parenting Decision Making Guardianship Spousal Support Property Division Child Protection Protection Order Adoption Other Please Specify: Do You Currently Have a Lawyer? Yes No Please Provide the Name of Lawyer and Law Firm Does the Opposing Party Currently Have a Lawyer? Yes No Please Provide the Name of Lawyer and Law Firm Have You and the Opposing Party Started Any Legal/Court Proceedings?(Required) Yes No Not Sure Who Started the Proceedings?(Required) Which Court is Your File In?(Required) Provincial Supreme What Registry is Your File In?(Required) Are There Any Current Provincial Or Supreme Orders Affecting You and the Opposing Party? Yes No Please ElaborateMarriage/Co-Habitation & Separation InformationStart Date of Co-Habitation(Required) MM slash DD slash YYYY Are You Married?(Required) Yes No Where Were You Married? State / Province / Region Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Date of Marriage(Required) MM slash DD slash YYYY Are You Currently Separated/Divorced?(Required) Yes No Date of Separation/Divorce(Required) MM slash DD slash YYYY Are There Any Verbal or Written Agreements Between You and Your Spouse? Yes No Please Provide Details Who is Currently Living in the Matrimonial Home? Your Marital Status Immediately Before This Marriage? Never Married Divorced Widowed Your Spouse's Marital Status Immediately Before This Marriage? Never Married Divorced Widowed Are There Any Safety Concerns, Or Has There Been Any Physical Violence Towards You or the Children?Are There Any Protection Orders in Place? Yes No Please Specify: Have You Received Any of the Following During Your Marriage or Co-Habitation? Inheritance A Substantial Gift From Someone Other Than Your Spouse Money From a Personal Injury Claim Money From a Life Insurance Policy Please Specify: Has Your Spouse Received Any of the Following During Your Marriage or Co-Habitation? Inheritance A Substantial Gift From Someone Other Than You Money From a Personal Injury Claim Money From a Life Insurance Policy Please Specify: Assets and DebtsYour Individual Assets:Type of AssetValue of Asset ($) Add RemoveSpouse's Individual Assets:Type of AssetValue of Asset ($) Add RemoveJoint Assets:Type of AssetValue of Asset ($) Add RemoveYour Individual Debts:Type of DebtValue of Debt ($) Add RemoveSpouse's Individual Debts:Type of DebtValue of Debt ($) Add RemoveJoint Debts:Type of DebtValue of Debt ($) Add RemoveInformation About Your ChildrenChild(ren) InformationName (Please Include Middle Names)Date of BirthPlace of BirthCurrently Resides With (You, Your Spouse, Shared, Other)Child's Relationship to You (Biological, Stepchild, Adopted) Add RemoveAre There Orders In Place With Respect to the Children? What is the Decision Making/Parenting Responsibilities Arrangements for the Child(ren)? How Much Times Does Each Parent Spend with the Child(ren)? What is the Current Child Support Arrangements for the Child(ren)? Do You Have Any Special Expenses for the Child(ren)? Yes (Please Provide Amounts and Details Below) No Special ExpensesChildcareAmount ($)Item Details: Add RemoveTutitionAmount ($)Item Details: Add RemoveMedical or Dental ExpensesAmount ($)Item Details: Add RemoveExtracurricular ActivitiesAmount ($)Item Details: Add RemoveOtherAmount ($)Item Details: Add RemoveYour Legal ProblemBriefly Descibe Your Legal Problems or the Issues You Would Like to Discuss During Your Consultation(Required)Briefly Describe Any Additional Information That You Think Relates to Your CaseTerms of Service and Waiver of Liability(Required)Please read the following, and if there is anything that you do not understand, please ask the advocates before signing. In seeking legal information and assistance from NSCR, I understand that: 1. The North Shore Legal Advocacy Program is a program of North Shore Community Resources (NSCR) and is offered free of charge. 2. NSCR Advocates are not Lawyers. 3. The NSCR Advocate is here to provide me with legal information and/or referrals, and, if it is within the Advocate’s experience and our funding mandate, legal advice and/or legal representation. 4. All information given by me will be held in confidence, unless I authorize the NSCR advocates to release information, except that I give my permission to NSCR to disclose all relevant information regarding my file: a. to designated staff of NSCR on a need to know basis; b. to any organization or individual deemed necessary by NSCR for the proper conduct of my file; and c. to the Law Foundation of British Columbia, which funds the Program, for the purpose of evaluating the effectiveness of the advocacy program it supports, on the condition that any personal information is to be kept in the strictest confidence. 5. NSCR reserves the right to limit the amount of time that may be spent with me by NSCR Advocates. 6. NSCR reserves the right to refuse or withdraw service, for reason including, but not limited to, the following: a. You fail to meet any eligibility criteria set out by our funder. b. The advocate has exceeded the amount of time NSCR can dedicate to one client. c. NSCR learns of a conflict of interest that would make it unethical for us to continue to act for you. d. You mislead NSCR or its advocates of the facts, or you do not give us all the facts and documents relevant to your legal problem. e. You do not keep us up-to-date on your contact info; do not respond to us in a timely way; or refuse to cooperate with reasonable requests necessary to pursue your case. f. You instruct NSCR to conduct your case in a manner that, in the opinion of supervising lawyer, is unreasonable. g. You behave rudely or abusively towards NSCR staff of advocate(s). h. There is a breakdown in the advocate-client relationship. i. You have obtained assistance or representation elsewhere. 7. I release NSCR’s employees, directors and volunteers, their heirs, executors, administrators, successors, assigns, Servants or agents respectfully, of and from all actions, claims and demands, whatever and wherever, which I or any of my heirs, executors, administrators, successors, assigns, servants or agents hereafter shall or may have which in any way arose out of, or developed from, or which may at any time in the future result, or in any way arise out of, or develop from the services, I receive from anyone associated with any NSCR Advocacy Program. I have read this contract carefully and agree with it.AUTHORIZATION AND CONSENT TO RELEASE INFORMATION.(Required)I give my consent for the release of any information in my file, whether considered confidential or privileged, to the below-noted Legal Advocate(s) with the North Shore Legal Advocacy Program at North Shore Community Resources. I understand I may revoke this consent at any time.Christopher MottersheadType Full Name(Required) Date(Required) MM slash DD slash YYYY Please note that to evaluate and improve our legal services to you we will ask all clients to complete a voluntary survey. We’d very much appreciate you taking the time to complete the survey when we send it to you. Thank you, CONSENT TO DISCLOSURE OF PERSONAL INFORMATION(Required)I understand that North Shore Community Resources receives funding from the Law Foundation of British Columbia. In order for the Law Foundation to evaluate the effectiveness of the advocacy programs it funds, Law Foundation staff or their agents may request to review your file. Any review by the Law Foundation would be solely to evaluate the services of North Shore Community Resources and personal information would be kept in the strictest of confidence. I consent to North Shore Community Resources disclosing my personal information to the Law Foundation of British Columbia for the purposes of evaluating North Shore Community Resources’ advocacy program funded by the Law Foundation of British Columbia.
