Referral / Request Form

  Referral to:
     
  Referral from  
  Name
  Email
  Telephone (10 digits only)
     
  Please describe yourself
     
  Client Info  
  Client Type
  First Name
  Last Name
  Address

Postal code:
  Is it okay to send mail to this address? YES    NO
  Email
  Telephone (10 digits only)
  Is it okay to leave messages at this number? YES    NO
     
  Gender Male    Female
  Age
  Language(s) spoken
   
  Financial Eligibility  
Does the Client meet the financial eligibility criteria for your particular pro bono organization?

YES     NO
  If No, or if you are an advocate or a private lawyer, state the Client’s Gross Family Income (Monthly):
   
Please indicate the law areas of the case
Aboriginal LawAdmin-GeneralAdmin-PensionAdmin-WCB
Admin-WelfareCharities / Non-ProfitCivilCivil Procedure
ConstitutionalContractsCorporate / CommercialCriminal
Debt-BankruptcyDebt-CollectionsDebt-ForeclosureEducation
Employment-OtherEmployment-Wrongful DismissalEntertainmentEnvironment
FamilyHealthHousing- Residential TenancyHousing-Other
Human Rights & PrivacyImmigrationInsuranceIntellectual Property
MediationReal EstateTaxationTorts-Intentional & Other
Torts-Personal Injury & NegligenceWills & Estates
  Opposing Party  
  Name
  Relationship (if relevant)
  Counsel (if known)
   
  Possible Limitation dates
     
  Provide a concise description of the facts and circumstances that give rise to the Client’s claim or defence
  Provide a concise description of the particular type and scope of pro bono assistance that the Client requires from a Roster Lawyer in order to advance or meet his/her case
Did you provide a copy of the APB Roster Program Client Information Sheet to the Client?

YES     NO
Where relevant, did you advise the Client of possible assistance through Legal Aid, duty counsel programs or other pro bono programs?

YES    NO
Did the Client consent to the release of his or her personal information for the purpose of acquiring pro bono asistance through Access Pro Bono Society of BC?

YES     NO
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