Law Advocacy Online Referral Form

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Burnaby Family Life

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Law Advocacy Online Referral Form - New Item

⚠ There are items in this form that require your attention

Title *

Today's Date: *

Full Name (First and Last): *

Date of Birth: *

Email Address (where it is safe to email you): *

Phone Number (where it is safe to call you): *

When we call, is it safe to tell you are we calling from Burnaby Family Life: *

What city do you live in: *

Family Law Advocates can only serve qualifying residents of Burnaby, Vancouver, and New Westminster, BC.

Community Law Advocates can only serve qualifying residents of Burnaby, BC.

I require support with the following: *

I need help with: *

Child support

Parenting arrangements

Property division

Divorce

Family violence

Tenancy/eviction/landlord concerns

PWD or CPP-D

Income assistance

Canada Child Benefit

Employment concerns

Other (please indicate below in specify value box)

Specify your own value:

Full Name of Opposing Party in your case (Family Law: ex-spouse, partner, or party to the case and Community Law: landlord, ex-partner, party to your case) *

Note for family law related issues this information is required. This information is collected only to ensure there is no conflict of interest. If no opposing party, please indicate not applicable.

Do you have any upcoming hearings, court dates, or deadlines to submit legal documents or applications? *

If you have indicated "yes" to having upcoming hearings, court dates, or deadlines to submit legal documents or applications, please let us know the first upcoming confirmed date:

Are you concerned for your safety or the safety of your children? *

For those seeking Community Law Support, have you been served an eviction notice?

For those who have been served an eviction notice, please indicate date of eviction:

Do you require language support? If yes, please indicate in what language?" *

ADMIN ONLY (DO NOT EDIT) Contacted: *

Yes- eligible for Family Law Advocacy Program

Yes- eligible for Community Advocacy Program

Yes- ineligible

Yes- eligible for Law Advocacy Program

Yes- remain as new for additional services

This field is for admin purposes only, please do not edit.

ADMIN ONLY (DO NOT EDIT) Date of Contact:

Attachments:

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