Van Nuys Self-Help Legal Access Center

First Name: / Middle: / Last:
Address: / Ethnicity:
 Asian/Pacific Islander /  White
City: State: Zip Code: /  African American /  Other
 Hispanic Origin /  Native American
Home Phone: / Date of Birth: / Do you live in L.A. County? / Sex:
Yes No /  Male Female
Have you ever been served with a restraining order?
Yes
No / Do you have an attorney?
 Yes
 No / Education:
 Did not finish High School
 High School Graduate/GED
 Some College
 College Graduate / Total Monthly
Household Income:
$______
 NO Income
How many in your home?:
Adults______
Children______/ Is this your first visit to the center?
Yes
No / What is your primary language?
 English  Spanish
 Farsi  Tagalog
 Russian  Other / How did you hear about
the Center?
 Court  Bar Association
 Legal Aid  Friend/Family
 Other ______
Why are you visiting the Center?
Only Check off 1 box:
I have finished filling out the forms and I need them reviewed
I am here for the class
I want to start a Divorce.
I was given Divorce papers by spouse.
My spouse responded to the divorce.
My spouse did not respond to the divorce and I need to do the next step.
My final divorce papers were sent back because something was wrong.
I want to change the child support order I have now.
I want to change the custody and/or visitation order I have now.
I want custody and/or visitation and I am not married to the other parent / I received an eviction.
I want to start an eviction.
I am being sued because of a car accident.
I am being sued because of a credit card bill.
I am being sued because of a medical bill.
I want a restraining order.
 Other:______
Statement of Understanding

I am asking that the Self Help Legal Access Center help me with information about my case.

Please sign your initials after you read each statement below. I understand that:

  • The Center is here to help me help myself. ______(initial here)
  • The Center will be giving me legal information. ______(initial here)
  • The Center will NOT be giving me legal advice. ______(initial here)
  • The Center is available to help both parties. ______(initial here)
  • The Center is NOT representing me and this is NOT a private meeting ______(initial here)

I have read and understand the Statement of Understanding written above.

Signature: ______Date: ______

OFFICE USE ONLY/USO DE OFICINA SOLAMENTE

Taken care by Paralegal
(circle your name) / Vanessa
Van Nuys / Norma
Pomona / Reyna
Antelope Valley / Diana
Back-up
Volunteer / Back-up / Robby / Bea / Sheila
JusticeCorps / Sharie / Ronnette
Check off Type of Assistance Provided:
(numbers are for administrative purposes only)

DIVORCE

/

PATERNITY

 / 32 / Divorce WS 1 /  / 36 / Paternity WS 1
 / 32 / Divorce WS 2 /  / 226 / Paternity Judgment WS
 / 125 / Divorce WS 3 /  / 36 / Paternity (Non WS)
 / 32 / Divorce (Non WS) /  / 226 / Paternity Judgment (Non WS)
 / 130 / Divorce Response /  / 130 / Paternity Response
 / 32 / Divorce Request for Trial Setting /  / 36 / Paternity Request for Trial Setting
 / 32 / Divorce Default Setting /  / 36 / Paternity Default Setting
 / 32 / Divorce MSC/Trial Brief /  / 36 / Paternity MSC/Trial Brief
 / 126 / Divorce Judgment (Non WS) /  / 131 / Order to Show Cause Initial – Paternity
 / 127 / Order to Show Cause Initial – Divorce /  / 131 / Order to Show Cause Mod - Paternity
 / 127 / Order to Show Cause Mod - Divorce /  / 131 / Order After Hearing
 / 127 / Order After Hearing
 / 31 / Joint Petition for Summary Dissolution
OTHER FAMILY LAW / NON-FAMILY LAW
 / 33 / Guardianship /  / 225 / Starting an Eviction
 / 34 / Name Change Adult /  / 63 / Answer to Unlawful Detainer
 / 34 / Name Change Child /  / 102 / Civil Harassment
 / 03 / Contract Answer

OTHER

/  / 94 / Auto Accident Answer
 / 99 / Other
Level of Service:
Scheduled for Workshop / Assisted at Workshop / Individual Assistance / Gave "How to" and forms only / Referred
Notes:
Referred Litigant to
Check off only 1 (the primary referral):
 / Legal Services /  / Lawyer's Referral
 / Family Law Facilitator /  / Family Law Conciliator
 / Dispute Resolution/Mediation Services /  / Consumer Affairs
 / Governmental Agency /  / Non-Profit Agency

F:\USERS\SELF HELP CENTERS\Van Nuys\Intake\Intake Van Nuys English.doc January 27, 2006