Intake Form - Don Valley Community Legal Services

Referral Information (if an agency is supporting you in completing this form):

Referring Agency’s Name

Referring Staff Person’s Full Name

Referring Staff Person’s Telephone Number

Referring Staff Person’s Email

Your Personal and Contact Information:

Full Name*

Date of Birth*

Phone Number*

Alternative Number

Please indicate when is the best time to contact you (i.e. morning 9 am to 12 pm vs. afternoon 1 pm to 5 pm)*

Current Address*

Unit/Apt/Suite

City*

Province*

Postal Code*

Interpreter Required

Language

Accommodation:

Please let us know if you require accommodations relating to accessibility.

Special Needs/Accommodation Required:

Indicate any accommodations you would like us to be aware of:

Income Information:

We can only help people with low incomes. However, in most circumstances if your income is too high, we can provide you with limited summary legal advice and/or referrals.

What is your main source of income?*

What is the monthly amount?*

Do other members of your household have an income?*

If so, what is the total monthly amount of their income?*

Number of adults in your household (including yourself)*

Number of children in your household*

Statistical Information:

The collection of this personal information is authorized under applicable legislation. Don Valley Community Legal Services is collecting and using this information so we can serve you better, and work to improve access to justice for all communities. You do not have to answer these questions. Don Valley Community Legal Services will not withhold any program, service or benefit if you choose not to provide this information. You can also request to withdraw your consent or change this information at any time.

Gender Identity

Ethno-Racial Group

Area of Law:

What is your legal issue?*

Housing LawODSP - Ontario Disability Support ProgramOW - Ontario WorksCPP - Canada Pension PlanImmigration and RefugeeEmployment LawAffidavit or Notarial True CopyOther

Please provide a brief description of your legal issue and indicate if you have any legal deadlines (e.g. a filing deadline or hearing date).

Please attach copies of any documents relating to your legal issue. For example, an eviction notice or a letter from Ontario Works. (formats PDF/docx/JPEG/PNG/ limit 25mb)