Bringing Justice Home Application

You are applying for legal services. Any information supplied during this application process is confidential. This application is NOT an agreement for legal services. An attorney/client relationship is not created by submitting this application. Once your application is submitted, Bringing Justice Home will evaluate your eligibility for services.

Referred by

Have you contacted a BJH attorney before?

Yes

No

I don't know

If so, when?

First Name

Middle Name

Last Name

Date of Birth

Have you ever been known by another name before? (Prior / Maiden / Nickname)

Yes

No

Prior / Maiden / Nick Names

Where are you currently living? (If you live in a domestic violence shelter, please just write the name of shelter. If you are staying with friends/family, we need at least the city and state where you reside)

Address

City

State

Zip Code

Is this a SAFE address to send mail to?

Yes

No

SAFE Mailing Address

Address

City

State

Zip Code

Phone Number

Is it safe for us to leave a message at this number?

Yes

No

Is it safe for you to receive a text message at this number?

Yes

No

Special instructions for calling? Let us know if there are times of the day that are safer than others or if you would prefer that we contact your through another method

Email Address

Is it safe for us to email you at this address? Email is not secure and if the other party in your legal matter has had access to your phone or email account in the past, correspondence could be intercepted by him/her

Yes

No

Gender

Please enter your gender

Enter other ethnicity

Bringing Justice Home serves individuals regardless of their immigration status. However, your immigration status could impact those legal remedies available to you, and therefore it is helpful for us to know this information

Were you born in USA?

Yes

No

If no, are you a US Citizen?

Yes

No

If no, Immigration Status:

Is english your first language?

Yes

No

Primary Language

Do you have a disability impairing your ability to work or perform major activities of daily living?

Yes

No

What accommodations do you need from Bringing Justice Home, if any?

Highest Completed Education

Opposing Party's Information

Please give us information on the other party involved in your legal matter. This could be a current or former partner/spouse or another individual, AND your legal issue could involve a company like an employer, landlord, school, or other entity or agency

Check all that apply to your situation

Person

Company / Entity

Person

First Name

Middle Name

Last Name

Gender

Please enter their gender

Date of birth

Phone/Mobile

Are there more parties involved in the situation?

Yes

No

Further party information

Name (First, Middle, Last)	Gender	Date of birth

Company / Entity

Company / Entity Name

Phone

Please include the other party's contact information if you know it. We will not contact any person without your permission.

Type

Employer

Landlord

School

Other

Other:

Your Relationship to Opposing Party (check all that apply)

Current Spouse (licensed marriage)

Former Spouse (divorced)

Current intimate partner (unmarried or "common law marriage")

Former intimate partner (previously resided together)

Dating relationship (never lived together)

Other family / household member

Acquaintance

Stranger

Other

If Other, please specify

Your Marital Status

Date of Marriage

Location of Marriage

How long have you lived in Colorado?

Have you experienced domestic violence, sexual assault, stalking, or human trafficking with the opposing party listed above?

Yes

No

Bringing Justice Home only serves individuals who have legal issues as a result of domestic violence, sexual assault, or stalking. If you feel your legal issues has been caused by one of these issues, please add the name of the person who committed those acts above in addition to the name of the person or entity that is involved in the current legal issue.

If your legal issue is not as a result of domestic violence, sexual assault, or stalking, Brining Justice Home is not the correct agency to assist you with your legal matter. Please see the following link for other legal resources:

Income

BJH does have income guidelines for those who can receive legal services from our office. Our office considers lack of access to the other party’s income as well as access to legal resources in your area when considering applications. The following information will assist us in determining eligibility for services but also possible legal remedies and resources which may be available:

Monthly Gross Income (BEFORE Taxes and Expenses, please include all sources of income listed below)

Applicant Only

$

Applicant Only

$

Sources of income

Check all that apply

Income

Employment

Name of employer

Welfare / Public Assistance:

Social Security, SSDI, SSI

TANF, OAP, Food Stamps

Other sources of income

Unemployment, Worker's Compensation

Dividends, Interest, Investment

Rental Properties

Child Support, Maintenance

Pension, VA Benefits

Support received regularly from another person

Name of other person

How many people in your household that you support?

# of Adults

# of Children

Assets (In Applicant’s Name Only):

Savings Account

$

Checking Account

$

401K or other Retirement Account

$

Shared Accounts (accounts with opposing party):

Savings Account

$

Checking Account

$

401K or other Retirement Account

$

Children

Do you have children under the age of 18?

Yes

No

How many children?

Please enter your children's info below (click the + icon to add more children)

Child's Full Name	Date of Birth	Shared w/ Opposing party?

How long have the children lived in Colorado?

Has the Department of Human Services/Child Protective Services ever been involved with your family?

Yes

No

Was a court case initiated by DHS/CPS?

Yes

No

Legal Info

Please provide a brief description of your current legal issue:

Are there any open court cases?

Yes

No

Court Case Info (click the + icon to add more)

Type of case:	Case number:	County:	Upcoming court dates:

Are there any protection orders regarding you or the other party in effect that you are aware of?

Yes

No

Who is the protected party?

Case #

Have the police ever been involved?

Yes

No

Please briefly describe the circumstances of the most recent arrest, police call:

Submit

Please check all of the following to acknowledge you understand.

I understand that children are not allowed to attend legal appointments

I understand that BJH does not provide child care (Please let us know if lack of child care is a barrier to obtaining legal services)

I understand that my appointment will take place at 421 Parker Street, Fort Collins, unless otherwise specified by a BJH representative

I understand that it is my responsibility to notify BJH as soon as possible if I am unable to attend my appointment, either by calling: 970.224.2966 or sending an email to: [email protected]

I understand that my initial appointment is to receive brief advice / brief services ONLY and I will not retain an attorney at this meeting. Cases are evaluated after the initial consultation by the BJH team to determine if the applicant is eligible for additional services

I understand that it is my responsibility to follow up with BJH after my initial appointment to check the status of my application

YOUR ELIGIBILITY TO RECEIVE SERVICES WILL BE FURTHER EVALUATED. AT THIS TIME, BJH DOES NOT RESPRESENT YOU IN ANY LEGAL MATTER INCLUDING THIS ONE.

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Opposing Party's Information

Income

Sources of income

Assets (In Applicant’s Name Only):

Shared Accounts (accounts with opposing party):

Children

Legal Info

Submit

YOUR ELIGIBILITY TO RECEIVE SERVICES WILL BE FURTHER EVALUATED. AT THIS TIME, BJH DOES NOT RESPRESENT YOU IN ANY LEGAL MATTER INCLUDING THIS ONE.

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