Chosen Family Law Center Client Intake Questionnaire

QUALIFICATIONS:

All CFLC clients must be below 250% of the federal poverty line (financial documentation of income and assets must be provided), a self-identified member of the LGBTQ community. We serve residents of the following NY Counties: All 5 boroughs of NYC, Westchester County, Putnam County, Dutchess County, and Ulster County.

We are proud to offer assistance to low income residents of New York who qualify. We are no longer accepting New Jersey clients at this time.

Please see the list of qualifications for income and geographic location on the right side of this form ---->.

If you believe you qualify, please submit all of the information required below and we will get back to you as soon as we can!

PLEASE NOTE: By filling out this form you recognize that SERVICES ARE NOT GUARANTEED and/or we may need to place you on a waiting list. Our attorneys are volunteers and there is often a wait for services.

Are you (the person seeking services) over the age of 18?

Yes

No, I am a minor

Note: If you are a minor, you will need a person over 18 to sign documents for you.

Name You Currently Use

Full Legal Name

(If you do not wish to submit this information here, we can also accept it by telephone.)

Pronouns

Mailing Address

(If you do not wish to submit this information here, we can also accept it by telephone.)

County of residence (We serve residents of the following NY counties: all 5 boroughs of NYC, Westchester County, Putnam County, Dutchess County, and Ulster County.)

Telephone

Email address

Are you able to come to our NYC office IN PERSON during business hours to sign legal documents? Most legal documents will need to be signed and notarized in person. Ample notice will be provided.

Yes

FINANCIAL INFORMATION
We serve clients up to 250% of the federal poverty line based on household size. Please consult the chart at https://chosenfamilylawcenter.org/income-and-eligibility to determine if you qualify.

How many ADULTS do you share finances with as a household? A "financial household" is those who pay for things together, not necessarily who lives under your roof. Do not include roommates who you don't share finances with, but DO include spouses, partners if you share bills/food or take care of children together. If you share finances, we need income documentation for everyone in the household.

1 (only myself) 2 3 4 5+

How many TOTAL people, including all ADULTS and CHILDREN, live in your financial household?

1 (only myself) 2 3 4 5 6 7 8 9+

What is your total HOUSEHOLD income for all of the people noted above? (Add up the total combined income of everyone in your house who you share finances with) $_________/year. If yours is the only income and you put 1 for the last question, please put the same $$ number as the previous question.

For income verification, we will ask you to provide income documentation (W-2 or tax returns) for your spouse, partner or other household members with whom you share your finances.

Please approximate your total net worth if it is more than $20,000. Outside of your annual income, your net worth is the TOTAL CASH VALUE of all your financial accounts (checking, savings, 401k, trust) and any real estate holdings MINUS YOUR DEBT. If it is less than $20,000, to put $0 is fine.: $___________

We may ask for documentation of this as well.

Have you ever been subject to criminal proceedings or a civil law suit of any kind? If so, we will need to discuss that with you during intake as this may affect the process or services available.

Yes No I prefer to speak in person.

How did you hear about CFLC?

Social Media Internet Search Friend/Colleague (direct referral) Saw Andy or Diana at a public speaking event Doctor/Therapist/Clinic referral Word of Mouth Flyer

Any other comments?

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Chosen Family Law Center, Inc.

The Chosen Family Law Center, Inc. is a 501(c)(3) nonprofit corporation dedicated to cultivating equitable social and legal recognition of Lesbian, Gay, Bisexual,Transgender, Intersex (LGBTI) and polyamorous families and individuals, as well as other underserved family forms such as platonic co-parents or multigenerational families; eliminate prejudice and discrimination and defend human, civil, and other rights for these communities; and offering education to lawyers, therapists, and other professionals to enable them to best serve these communities.