Family Defense Center
Prospective Client Information Sheet
This Prospective Client Information Sheet provides information the Family Defense Center requires in order to consider each request for legal services. By completing this form, you are signifying that you want the Family Defense Center to consider your request for legal services. The Family Defense Center assesses cases for merit and for available resources to provide the services requested. The Family Defense Center operates under specific case handling/case acceptance guidelines, which means that some meritorious cases will not be accepted when they are outside of the Center’s service area or guidelines or when the Center’s available resources are not sufficient to handle the case. COMPLETING THIS FORM DOES NOT CREATE AN ATTORNEY-CLIENT RELATIONSHIP. HOWEVER, THE INFORMATION YOU PROVIDE TO OUR OFFICES WILL BE CONSIDERED CONFIDENTIAL UNLESS AND UNTIL YOU AUTHORIZE ANY DISCLOSURE.
Date:______
First Name:______Last Name:______
Please identify your preferred number with an “X”:
Home Phone Number:______Preferred: _____
Cell Phone Number:______Preferred: _____
Other Phone Number:______Preferred: _____
Date of Birth:______E-mail Address:______
Mailing Address:______
Street Address
______
City, State, Zip CodeCounty
County in which the DCFS case is taking place: ______
Are you seeking services for yourself or on behalf of someone else? _____Self Only ____Someone Else ____Both
How did you hear about The Family Defense Center?
If someone else or both, for whom else are you seeking services? ______
If you are seeking services on behalf of someone else, why are you contacting us instead of the person needing legal services (i.e., is that person is under age 18 or is incapacitated/unavailable in some way?)
Please check the appropriate boxes for statistical purposes:
Gender:____ Male____ Female ____ Prefer not to answer
Is your household limited English proficient? ____ Yes ____ No
Primary language spoken in the home: ______
Do you have a disability? ____ Yes ____ No____ Prefer not to answer
What is your ethnic or cultural background?
___ African American or Black___ Native American___ Asian or Pacific Islander
___ Latino/a or Hispanic___ Caucasian___ Multiracial ___ Other
What is your marital/relationship status?___ Married___ Divorced___ Single
___ Living with a partner___ Widowed___ Engaged___ Separated
Please identify by FIRST AND LAST NAME any individuals who are potential “adverse parties”* to your case:
*An adverse party is any person who has a personal interest in the same matter and is opposed to the caller’s interests in that matter. Example: an ex-spouse who is calling the hotline in order to gain an advantage in a custody dispute.
Name of Spouse/Partner if applicable: ______
Spouse/Partner Date of Birth:______
Spouse/Partner Phone Number:______Cell____ Home
Spouse/Partner Email Address:______
Is your current Spouse/Partner the biological or legal parent of any of your children? ____ Yes____ No
If yes, which children: ______
What are the names, dates of birth, and parentage of your children and any other children involved in your case?
______
NameDate of birthParents
______
NameDate of birthParents
______
NameDate of birthParents
______
NameDate of birthParents
______
NameDate of birthParents
Who lives with you in your household and what is your relationship with each person?
______
NameDate of birthRelationship
______
NameDate of birthRelationship
______
NameDate of birthRelationship
______
NameDate of birthRelationship
______
NameDate of birthRelationship
______
NameDate of birthRelationship
Do you currently work?____ Yes ____ No If so, where do you work? ______
If not, where did you last work and when did that end?
______
Do you presently, have you ever, or would you like to work with children in any kind of professional capacity (i.e., nurse, doctor, teacher, social worker, day care worker)? ______
Do you hold any licenses related to working with children? ______
If you are a student, what are you studying?______
Does your spouse/partner work? ____ Yes ____ NoIf yes, where does s/he work? ______
What is your combined gross household income including all sources of income? Monthly
Annually
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70 E. Lake St. Suite 1100 · Chicago, IL 60601 · Phone: 312-251-9800 · Fax: 312-251-9801 ·