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Date:
Referring Agency (if an agency is supporting a client in completing this form):
Referring Staff Person (if an agency is supporting a client in completing this form):
First Name: *
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OntarioBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutAlbertaPrince Edward IslandQuebecSaskatchewanYukon
Is there a particular time that is good, or bad, for contacting you?
What sort of problem do you have? (Some examples in brackets.)
Housing Law (eviction, repairs, harassment by landlord, rent subsidy taken away)ODSP – Ontario Disability Support Program (benefits denied, cut off, overpayment)OW – Ontario Works (denied OW, benefits cut-off, overpayment)CPP – Canada Pension Plan (retirement benefits or CPP disability benefits)Immigration (not refugee applications – those are referred to Legal Aid)Employment Law (wrongful dismissal, employment standards, EI)Other: we will try to refer you elsewhereNone of the above
Please attach copies of any documents relating to the problem. For example, an eviction notice or a letter from Ontario Works.
Where do you live?BramptonOrangevilleShelburneElsewhere in Dufferin CountyCaledonElsewhere: we will refer you to a legal clinic in your area
We can only help people with low incomes. However, if your income is too high, we can still provide some summary advice.
What is your main source of family income?Ontario Works (OW)Disability Support Program (ODSP)Canada Pension Plan (CPP)Old Age Security (OAS) plus Guaranteed Income Supplement (GIS)War Veterans AllowanceWorkers’ compensation benefits that are temporary or threatenedNone of the above
If not one of those six sources of income, please answer these questions. We do not need this information if your main source of income is one of the six listed above.
Number of Adults in the Family:
Number of Children:
Total gross annual family income (before taxes):
If you do not want to answer a question (or don’t know the answer), just skip that question. None of this information is a requirement for getting help.
Gender IdentityFemaleMaleAgenderTransgender FemaleTransgender MaleOther
SexualityGay/LesbianHeterosexualBi-sexualQueerTwo SpiritedOther
Status in Canada:
Country of Origin:
Year of Arrival in Canada:
Or Born in CanadaYes
Level of Education:
Occupation:
Employment Status:
Housing (rent/homeless/etc.):
Ethno-racial identification:
Preferred language:
First language:EnglishOther
Interpreter required:YesNo
Special Needs/Accommodation Required:
It is very helpful for us to have a brief description of the type of problem being experienced.
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