REFERRAL FORM Applicant Name:
Date:
Address: City:
State:
Phone#:
Email:
Zip:
Is it safe to leave a message at the number/email provided:
Yes
No
Reason for Application (mark all that apply): Disaster Assistance FEMA, SSI/SSDI, SNAP, TEA, Medicare, Medicaid, Arkansas Works
Stress-Related Family Conflict Divorce, Custody, Guardianship, Orders of Protection
Flood Related Income Protection Unemployment, Criminal Record Sealing, Maltreatment Registry
Housing Insurance Denials, Contractor Scams, Land/Home Title, Foreclosure, Mortgage, Rent-to-own, Utilities
Landlord/Tenant Eviction, HUD, Utilities, Repairs, Rent Hikes
Document Replacement Birth Certificates, Driver’s Licenses, Social Security Cards
Planning Wills, Power of Attorney, Advance Directive, Future Disaster Planning
Consumer and Fraud Garnishment, Repossession, Bankruptcy, Debt Collection, Contract Disputes, Contract Review and Advice, Rent-to-own, Personal Property Damage
Preferred Language:
English
Español
Other:
Additional Information for the attorney:
The information shared in this screening form is strictly for purposes of determining whether you might benefit from a free consultation with an attorney who will never charge for services. Completion of this form does not create an attorney/client relationship and does not obligate the Center for Arkansas Legal Serivces (CALS) to help with your legal problem. Returning this form means that you agree to share this information with CALS and that a CALS representative may contact you to discuss your situation.
Client Signature:
Date:
Hernandez Return to: Gloria Email: ghernandez@arkansaslegalservices.org
, Bilingual Senior Intake Specialist for the Center for Arkansas Legal Services
Mail: 1300 West 6th Street Little Rock, AR 72201
Phone: 501-500-9367 Fax 501-376-3664