Chosen Family Law Center Client Intake Questionnaire

This is a secure form. All information will be kept confidential and used only for our internal records. If you prefer not to use this form please call us at 732-639-1657.

Please correct the errors described below.

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.

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

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.

We must verify all client incomes. For income verification, we will ask you to provide documentation such as your most recent tax return, a W-2 or paystub if you have one, or if you receive benefits or unemployment income, copies of your paperwork. If your income is llisted as $0, we will ask you to confirm this.
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.
We may ask for documentation of this as well.

Your information will be encrypted.

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