TLSC General Intake Form

Once your intake form is received, we will evaluate whether you are eligible to receive services.

If you are seeking legal advice for someone other than yourself, please use the THIRD PARTY INTAKE FORM.

Are you seeking legal advice for yourself or someone else? Myself    
Name *:
Address *:
City *:       State:       Zip:
County *:
Phone *:
Alternate Phone:
What is the best time of day to reach you by telephone?
Date of Birth *: (xx/xx/xxxx)
Ethnicity *:
Sex *: Female     Male
Do you receive Medicare? Yes     No
Marital Status:
Name of Spouse (if married)*:
Name of adverse party (the person or organization about whom you are complaining)*:
Are you disabled? Yes     No
Are you a veteran? Yes     No
Are you the spouse of a veteran? Yes     No
Are you the surviving spouse of a veteran? Yes     No
How many people live in your home?* Adults:     Children:
Average monthly income of your entire household?*
Yearly income of your entire household?
Source of that income (SSI, SSDI, Pension, employment, etc.)
Do you have assets, apart from your home and vehicles, such as: savings, stocks, bonds and other real estate? Yes     No
Briefly describe your legal problem:
limit 800 characters

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