North Shore Legal Advocacy Intake Form - Community Legal Services

North Shore Legal Advocacy Program Intake Form

Intake and Consent to Release Information

Personal Information

Name(Required)

First Middle Last

Alias or other name you are known by

Address

Street Address Address Line 2 City Province Postal Code

Home Phone Number(Required)

Cell Number

Work Number

Optional

Is it OK to Call You?(Required)

Yes

Can We Leave a Message?(Required)

Yes

Is Your Email Safe and Private?(Required)

Yes

Demographic Information

NSCR 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

Date of Birth

Marital Status

Household Size (number of people)

Ages of Children (if dependants)

Gross Household Income

Source of Income

Employed

Employed Insurance (EI)

CPP

Social Assistance (Welfare, PPMD, or PW)

Pension (Not CPP)

Other

Explain Other Sources of Income

My Race/Ethnicity is:

Do you self-identify as Indigenous?

Yes

Which of these do you self identify?

Indigenous

Métis

Inuit

Language(s) spoken at home, if other than English:

How did you hear about our services?

Name of Referring Organization

Please Specify

Type of Case

Please indicate the type of problem(s) that you want help with.

Income Security (Welfare, Disability, EI, CPP)

Housing

Debt

Other

Your Legal Problem

Briefly describe your legal problem.

Alternate Contact (optional)

To help us reach you in the event you move or your number changes, provide the name and work phone number of a trusted friend or family member whom we could talk to in order to reach you. We will only contact this individual to get updated contact information for you.

Opposing Party

If applicable, name the opposing party/parties in this matter and their relationship to you. For example: in an employment case, give your employer's name/in a housing case, give your landlord's name. The purpose of this conflict check is to ensure that we do not assist or represent a client whose interest adversely impact another clients.

Email of Opposing Party

Phone Number of the Opposing Party

Consent(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 our services are provided without legal fees. We request that you complete a voluntary survey in order to help us understand how we can improve our services

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.

We do not charge but will request each client to complete a Voluntary Survey about their experience at NSCR Legal. : In accordance with the Personal Information Protection Act, information collected will be used only as necessary to deliver services. We will not disclose any personal information to a third party without your expressed permission. I understand that I may revoke this consent at any time.