Family Intake and Consent Form

DADE LEGAL AID'S FAMILY DEPARTMENT OFFERS LEGAL SERVICES TO:

Miami-Dade County Residents (Must be living in Miami-Dade County for more than 6 months)
Low-income individuals
Your case MUST be an Initial Filing or you have been recently served:
For a Custody case – Your minor children must live with you
For a Divorce case - your minor children must live with you
For a Paternity case – your minor children must live with you

You have been served with a Custody, Divorce or Paternity and have ONLY filed a response

Family Intake and Consent Form

Today's Date(Required)

Please Select if you are requesting...(Required)

Divorce

Custody

Paternity

Referred by:

If you-or the other party have filed for or answered any court proceeding in family court please provide:

Case #

Did you use Self-Help or an attorney

Self-Help

Attorney

Attorney's Name

First Last

Your Information

Name(Required)

First Middle Last Suffix

Date of Birth(Required)

Social Security Number

YOU MUST LIVE IN MIAMI-DADE COUNTY TO APPLY FOR OUR SERVICES

Address(Required)

Street Address Address Line 2 City State ZIP Code

How many years have you been living in Miami-Dade County(Required)

Home Phone Number(Required)

Cell Phone Number(Required)

Email(Required)

Demographics

Citizen Status(Required)

I am a US Citizen

I am a Resident (Green Card)

No Status

Country of Birth(Required)

Do you speak English? If no, please select from the right.

Yes

Language Spoken

Ethnicity(Required)

Asian American

African American

Hispanic

Native American

Pacific Islander

White

Other

Marital(Required)

Education(Required)

High School Graduate

College Graduate

Graduate School

Unknown

Other

If you did not graduate, please select "Other" and enter the last Grade you completed.

Employment(Required)

Full time

Part Time

Retired

Unemployed

Are you...(Required)

A Veteran

In Bankruptcy

In Foreclosure

Own a Business

Own Real Estate

Filed for Divorce

Filed a Restraining Order

No to All

Household

Number of people under 18 in your household(Required)

Number of people 18 and over in your household(Required)

Gross Income

Source of Income

Frequency (weekly, biweekly, etc..)

Amount

To add additional sources of income, click on the plus icon on the right and enter the information. Sources of income may include: Alimony, Child support, Employment, Food stamps, Disability, Retirement, SSI, etc...

Do you own a business?(Required)

Yes

No

Business Name

Business Phone

Number of Employees

Other Party's Information

Name (Spouse or Parent of Child)(Required)
First Middle Last Suffix

Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Date of Birth
MM slash DD slash YYYY

Social Security Number

Source of Income

Amount per Month

Does the Other Party own a business?(Required)

Yes

No

Business Name

Business Phone

Number of Employees

Is the Other Party...(Required)
A Veteran
In Bankruptcy
In Foreclosure
Own a Business
Own Real Estate
Filed for Divorce
Filed a Restraining Order
No to All

Children with the Other Party

Do you have children with the other party?(Required)

Yes

No

Children
Name of Child
Date of Birth of Child
Who does the Child live with?

To add additional children, click on the plus icon on the right and enter the child's information.

How can we assist you?

Briefly explain your situation and what you would like Legal Aid to do for you

Acknowledgement

Based upon the information I have provided I may qualify to receive free legal services. If my case is initially accepted and I am referred to a staff attorney for a further intake appointment, the attorney will gather additional information necessary for the final review of eligibility. I agree and understand that until I have met with the attorney and Legal Aid has accepted my case, Legal Aid does not represent me, will not make any appearances on my behalf, and does not take any responsibility for my case. I understand and agree that if I fail to appear for the intake with an attorney, or do not provide necessary documents for my case, my file will be closed with this office, and I must reapply if I decide to proceed in the future.

I agree to the Terms & Conditions(Required)

Yes

No

Signature(Required)

In accordance with the Americans with Disabilities Act of 1990, persons needing a special accommodation should contact the ADA Coordinator, Eileen Coto, 305-579-5733x2240, ecoto@dadelegalaid.org; If hearing impaired you may call the Florida Relay Service telephone number, 1-800-955-8771 for assistance.

CAPTCHA

NOTE - PLEASE READ BEFORE COMPLETING THIS APPLICATION

DADE LEGAL AID'S FAMILY DEPARTMENT OFFERS LEGAL SERVICES TO:

*We DO NOT handle any Modifications, Reopening of cases or Post Judgement matters.
For more information, please contact the Receptionist at 305-579-5733 x 2222

Family Intake and Consent Form

If you-or the other party have filed for or answered any court proceeding in family court please provide:

Your Information

YOU MUST LIVE IN MIAMI-DADE COUNTY TO APPLY FOR OUR SERVICES

Demographics

Household

Other Party's Information

Children with the Other Party

How can we assist you?

Acknowledgement

*NOTE - PLEASE READ BEFORE COMPLETING THIS APPLICATION*

DADE LEGAL AID'S FAMILY DEPARTMENT OFFERS LEGAL SERVICES TO:

*We DO NOT handle any Modifications, Reopening of cases or Post Judgement matters. For more information, please contact the Receptionist at 305-579-5733 x 2222

Family Intake and Consent Form

If you-or the other party have filed for or answered any court proceeding in family court please provide:

Your Information

YOU MUST LIVE IN MIAMI-DADE COUNTY TO APPLY FOR OUR SERVICES

Demographics

Household

Other Party's Information

Children with the Other Party

How can we assist you?

Acknowledgement

NOTE - PLEASE READ BEFORE COMPLETING THIS APPLICATION

*We DO NOT handle any Modifications, Reopening of cases or Post Judgement matters.
For more information, please contact the Receptionist at 305-579-5733 x 2222