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CLRC Intake Form

Disclosures

By submitting an online application, you acknowledge that you understand the following:

  • We are a legal resource organization, so we can provide you with information about the laws that might pertain to your situation and we can provide resources that may be able to assist you in enforcing your rights. However, we do not provide legal advice, legal expert referrals, direct legal representation, or financial assistance.
  • Completing this intake form will provide us with some necessary information regarding your situation. After you have completed this form, it will be reviewed by a CLRC staff attorney, who may contact you for additional information. We will then contact you with the appropriate resources and information by phone or mail, depending on your situation. 
  • Any information that you provide is kept confidential.

Contact Information

Person With Cancer

(If you are contacting the CLRC on behalf of someone else)

 

Note: appropriate legal information and resources will be collected based on the city, county, and state of the person with cancer. Please indicate if another location should be used.

Only enter the dollar amount of your monthly net income.

 

Note: Resources are often based on income level and providing accurate information will help us to provide resources that are the best match for you.

 

 Reminder: Everything disclosed is confidential. Even if you give us permission to use your statistical information for research purposes, none of your personally identifying information (name, address, phone, etc.) will be disclosed to anyone outside of the CLRC.

Note: the CLRC is limited in the resources that we can provide if you have an attorney retained on this matter.

Intake Information

 

 

Specific Intake Questions

If you are contacting us regarding an employment issue:

If you are contacting us regarding a health insurance issue:

If you are contacting us regarding a disability issue: