Legal Services for Students Intake Form

*UTEID:

*Last Name:

*First Name:

*Middle Name:

*Date of Birth: (mm/dd/yyyy)

Gender: Select one... male female

Marital status: Select one... married single

Classification: Select one... Freshman Sophomore Junior Senior Graduate Student

Major:

*Local Street Address: Apartment Number:

*Local Address Zip Code:

*Preferred Phone Number:

*Home Phone Number:

Cell Phone Number:

*Permanent Phone Number:

*Email Address:

*Permanent Street Address: Apartment Number:

*Permanent Address City:

*Permanent Address State:

*Permanent Zip Code:

*Please indicate if we should not contact you at any of the above locations:
(if not applicable, enter "n/a")

*Citizenship: Select one... United States Argentina Australia Brazil Canada Chile England France Germany Hong Kong India Indonesia Ireland Italy Japan Malaysia Mexico Nigeria China (P R China) Pakistan Russia Scotland South Africa South Korea Switzerland Taiwan Ukraine Venezuela Other

Approximate Annual Income (excluding student loans): Select one... $0 to $5,000 $5,001 to $10,000 $10,001 to $15,000 $15,001 to $20,000 $20,001 to $30,000 $30,001 to $40,000 $40,001 to $50,000 over $50,000

Ethnicity: Select one... Anglo American Asian American Hispanic American African American International Other

How did you learn about our service?: Select one... UT home page other internet search media outlet parent/student/friend faculty/staff orientation off-site program on-site building information walk-in other

*Current Attorney, if any:
(if not applicable, enter "n/a")

Adverse party/parties (The person or group with whom you have a dispute): Give the complete name(s) and the address(es) and phone number(s) of the person(s) you are having trouble with:

*First Adverse Party's Name:

*First Adverse Party's Address:

*First Adverse Party's Phone:

*Is he/she a U.T. student?: Select one... Yes No

Second Adverse Party's Name:

Second Adverse Party's Address:

Second Adverse Party's Phone:

Is he/she a U.T. student?: Select one... Yes No

*Problem Description (2000 characters or less):

*LSS is occasionally contacted by parents or guardians regarding client legal matters. Do you authorize us to discuss this case with your parents or guardians? (You may modify this consent at any time by notifying us in writing.)
Yes No
If yes, please list the names of parents or guardians with whom we may discuss this case:

*How may this office help you? (2000 characters or less)

Please List 3 Preferred Appointment Dates At Least 48 Hours From Now

Please note: The LSS attorneys are only licensed in Texas. If your case involves issues outside of Texas, we may need to refer you to counsel in that jurisdiction.

* Appointment Date, First Choice:
Month: Select One... JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Day:      Select One... 12345678910111213141516171819202122232425262728293031
Time:    Select One... AM PM

* Appointment Date, Second Choice:
Month: Select One... JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Day:      Select One... 12345678910111213141516171819202122232425262728293031
Time:    Select One... AM PM

* Appointment Date, Third Choice:
Month: Select One... JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Day:      Select One... 12345678910111213141516171819202122232425262728293031
Time:    Select One... AM PM

I understand that effective legal assistance may only be given if this office receives my complete and truthful cooperation. I UNDERSTAND THAT ALL INFORMATION I GIVE DURING MY CONSULTATION WILL BE HELD IN STRICT CONFIDENCE AND WILL NOT BE MADE A PART OF MY ACADEMIC RECORD. I understand that it is essential that I inform this office of all relevant facts and keep the office updated of any material changes in my case. I understand that this office reserves the right to make the final decision as to whether legal representation will be provided in my situation. If this office decides to represent me, I will be presented with a Professional Services Agreement for my signature. I UNDERSTAND THAT UNTIL THIS DOCUMENT IS PROVIDED, THIS OFFICE IS NOT REPRESENTING ME.

I am currently enrolled as a student at The University of Texas at Austin. The above-described legal matter concerns my personal legal problem only, and is not the problem of a relative, friend, acquaintance, or other student at this University. My legal problem is not against another University of Texas student, nor is it against the University. Should this office agree to handle my case, I agree to 1) promptly notify the office of any changes to my address and/or telephone number; and 2) respond within 7 days to any written correspondence from the office.

I understand that email correspondence may not be confidential. If I choose to correspond with this office via email, I do so at my own risk, and I agree that this office will not be responsible for any unauthorized interception of such email message(s) by third parties. I also waive any objection to any potential breach of my confidentiality or privacy that I may have if the office responds to my email.

By submitting this form, I certify that all of the information listed above is true, correct, and complete to the best of my knowledge. I understand that failure to comply with any of the above requirements could result in denial of legal services from this office now and in the future.

I have read and understand the provided policies and procedures of the Legal Services for Students office.

*Acknowledgement Initials: