INJUNCTION FOR PROTECTION PROJECT (IFP) INTAKE / REFERRAL FORM Posted on July 24, 2019 by sara babb IFP Intake/Referral Form Today's Date * Next court date & time (if applicable) Name: First, Middle, Last * Date of Birth * Is there a safe phone number where you can be reached? * Yes No Safe phone number where you can be reached * Safe to leave a voicemail? * Yes No Safe to leave a text message? Yes No Safe E-mail where you can be reached * Safe address where you can receive mail (if available) Did you receive information about this referral form from a staff member at Women In Distress? * Yes No If you selected yes, please provide the name of the Women In Distress staff member who assisted you. * If you selected no, please provide name/agency and phone number of the person who provided this referral. Have you ever had a case with or against, or have you ever consulted with any of the following attorneys: Keila Belt, Frances Bethel, Juliana Chereji, Xiomara L. Cruz, Courtnie C. Copeland, Michelle Harper, Lisa Larmond, Anajah McNish, Julissa Nethersole, Arielle Nichols, Andrew Thomas, Jazmira Argueta Wheeler * Yes No If yes, which of these attorneys have you had a case with or against or consulted with? * Click here to chooseKeila BeltFrances BethelJuliana CherejiXiomara L. CruzCourtnie C. CopelandMichelle HarperLisa LarmondAnajah McNishJulissa NethersoleArielle NicholsAndrew ThomasJazmira Argueta WheelerOther If yes, which of these attorneys have you had a case with or against or consulted with? To your knowledge, has the person you are seeking an injunction against ever been represented by or consulted with any of the above attorneys? * Yes No Have you consulted with or signed an engagement/retainer agreement with another attorney for this matter? * Yes No What is the name, date of birth, and address of the person against whom you are seeking an Injunction? * How are you related to or connected to the person against whom you are seeking an injunction? * Do you have any minor (under 18) children in common with this person? * Yes No If so, what are their names and dates of birth? If you share children in common with this person, are you seeking: An Injunction as to the children as well Child support Time-sharing / visitation agreement Do you need an interpreter for a language other than English for your hearing or to speak with your attorney, if s/he does not speak your language? * Yes No If yes to the above, what language? Briefly describe the incident(s) [with dates & locations, etc.] that led you to seek an Injunction? * THE FOLLOWING INFORMATION IS OPTIONAL AND IS COLLECTED FOR STATISTICAL PURPOSES ONLY. THE SERVICES PROVIDED BY THIS CENTER ARE OFTEN FUNDED BY GRANTS THAT REQUIRE THE COLLECTION OF STATISTICAL DATA. THE STATISTICS GATHERED WILL BE COMPLETELY ANONYMOUS. WE WILL NOT RELEASE YOUR NAME OR ANY OF YOUR PERSONAL OR IDENTIFYING INFORMATION TO OTHER AGENCIES WITHOUT YOUR CONSENT. RACE / ETHNICITY Click here to choose your race/ethnicityBlack / African AmericanWhite Non-Latino/CaucasianHispanic or LatinoAsianAmerican Indian/Alaska NativeNative Hawaiian & Other Pacific IslanderMultiple RacesSome Other Race RACE / ETHNICITY AGE (check one) Click here to choose your age0-1213-1718-2425-5960 and older Are you a Veteran? Yes No Are you Deaf or Hard of Hearing Yes No Are you currently homeless? Yes No LIMITED RETAINER AGREEMENT: I do hereby retain THE INJUNCTION FOR PROTECTION PROJECT (IFP), solely for the purpose of obtaining and receiving information necessary to determine whether the matter that I have consulted the IFP Attorney about is a matter in which the attorney can or will provide me with representation. If, after reviewing the information related to my case, the attorney determines that s/he cannot accept my case, the Attorney will notify me of that fact, and will not act as my attorney with regard to this matter. I understand that even if the IFP Project is not able to represent me, it is possible that the IFP Project will provide me with a legal advice and counsel. The advice and counsel may be given in person or come in the form of a letter or telephone call. If I am provided with legal advice and counsel only, I understand that the IFP Project WILL NOT be representing me in Court or in any manner other than the consultation. If the Attorney accepts your case, you will be notified and asked to sign an Engagement Agreement to Accept Legal Services. CONSENT FOR RELEASE OF INFORMATION: I authorize the INJUNCTION FOR PROTECTION PROJECT (IFP) to obtain, inspect, copy and receive any information in my possession pertaining to myself and any minor children. This release is given without limitation and applies to both confidential and non-confidential information in my possession from any source and in any form (including, but not limited to substance abuse assessments/evaluations; psychological and psychiatric evaluations; therapy treatment plans and progress summaries; medical records; and urinalysis results, etc.). This release will expire within 90 days of the date below. By checking this box and signing below, you are confirming you have read and agree to the Limited Retainer Agreement and Consent for Release of Information above. * I have read and agree to the Limited Retainer Agreement and Consent for Release of Information Signature * Clear If you are human, leave this field blank. Submit
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