240-653-1175
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CLIENT INTAKE FORM
1. CLIENT INFORMATION
Full Legal Name
Preferred Name
Date of Birth
Email Address
Phone Number
Address
City
State
ZIP
Preferred Contact Method PhoneTextEmail
Language
2. SERVICES NEEDED
Please check all that apply:
Immigration Information/ResourcesImmigration Application AssistanceCitizenship/Naturalization InformationFamily-Based Immigration InformationEmployment-Based Immigration InformationDACA/Humanitarian Immigration InformationDocument Preparation/OrganizationTranslation/Language AssistanceLegal Services ReferralCommunity Resources/ReferralsEmployment AssistanceInternship AssistanceMedical & Health ResourcesCommunity/Housing ResourcesReferralOther
If Other, please specify
3. HOW CAN WE HELP?
Please explain what services or assistance you are looking for:
4. IMPORTANT INFORMATION
Do you have a deadline, appointment, hearing, or other important date? YesNo
If yes, please provide the date
Please explain:
Have you received assistance with this matter before? YesNo
If yes, please explain:
5. EMERGENCY / ALTERNATE CONTACT
Name
Relationship
6. HOW DID YOU HEAR ABOUT US?
Friend/FamilyWebsiteCommunity OrganizationReferralSocial MediaOther
7. CLIENT ACKNOWLEDGMENT
I understand that Legacy Immigration Services collects this information to better understand my needs, provide nonprofit services or referrals, and communicate with me regarding my request. I understand that submitting this form does not guarantee that services will be provided and does not create an attorney-client relationship.
Client Signature (type full name)
Date
FOR LEGACY IMMIGRATION SERVICES USE ONLY
Date Received
Staff Member
Follow-Up Needed? YesNo
Referral Made? YesNo
Follow-Up Date
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