LSNC LRD System

Welcome

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Your First Name

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Email

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Partner Organization

Password

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Applicant's Info

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Applicant's First Name

Applicant's Last Name

Age reported by applicant

Please enter a number between 1 and 120.

Phone

Preferred language (if other than English)

Can LSNC leave a voice mail on your phone?

Yes

No

Do you consent to receive text messages from LSNC?

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Do you have any barriers to reaching legal services during business hours (8:30–5)?

Yes

No

Do you have an email address?

Yes

No

Please provide a valid email

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Click here to use address autocomplete (recommended)

Home street address

Home city

Home state

Home ZIP

ZIP must be exactly 5 digits.

Is your mailing address different?

Yes

No

Please provide your mailing address

Please enter your mailing address.

Monthly Household Income

$

Income must be up to 7 digits (numbers only).

Household Size

Household size must be 1–99.

Select housing type

Rents

Owns

Unsheltered

RENTER BRANCH LOGIC

Please select at least one option below

1 of 6: Housing

I have papers or notices from my landlord or property manager. I need help with (example: 3 Day Notice to Pay Rent or Quit, Notice to Terminate Tenancy, etc). I am behind on my rent and worried about eviction. I have received a Summons/Unlawful Detainer (eviction court papers). I was given papers by a sheriff that say I have only a few days to move. My rental home/apartment is in disrepair and I can’t get it fixed. I have another housing-related problem (not indicated above).

2 of 6: Government benefits (income), consumer debt, and other income problems

I avoid calls from debt collectors / I cannot pay my debts / I want the calls to stop and I am on a small and fixed income (Social Security Retirement, SSI, GA, etc). My Social Security / SSI / Disability Income has stopped or decreased. I got a County letter saying I am no longer eligible for food stamps, Medi-Cal, GA, CalWORKs, etc. I am having problems with my pension -- I believe I earned a pension, but cannot locate it / am having problems with receiving pension payments. I have another problem or concern related to my income, benefits, or debt.

3 of 6: Financial exploitation

I signed a power of attorney (financial decisions) or advanced health care directive (health decisions) and I want to cancel it / I want to sign a power of attorney or advanced health care directive. I feel like someone is pressuring me about money and I would like some advice. I recently signed papers related to my finances or estate, but I am not sure what they say. I have questions or concerns about reviewing or preparing estate planning documents. I have another money-related problem (not indicated above).

5 of 6: Abuse & neglect concerns

I do not feel safe at home. I believe I, or someone in my care (for example, a grandchild) may be in imminent physical or emotional danger. My basic needs are not being met by a person who promised to take care of me (being fed, bathed, clothed, etc.). I have another fear or concern about my safety.

6 of 6: Other concerns

Yes No

OWNER BRANCH LOGIC

Please select at least one option below

2 of 6: Government benefits (income), consumer debt, and other income problems

I avoid calls from debt collectors / I cannot pay my debts / I want the calls to stop and I am on a small and fixed income (Social Security Retirement, SSI, GA, etc). I have Social Security / SSI / Disability Income that has stopped or decreased. I got a letter from the County that says it will stop giving me / I am not eligible for food stamps, Medi-Cal, General Assistance, CalWORKs, etc. I am having problems with my pension -- I believe I earned a pension, but cannot locate it / am having problems with receiving pension payments. I have another problem or concern related to my income, benefits, or debt.

3 of 6: Financial exploitation

I signed a power of attorney (financial decisions) or advanced health care directive (health decisions) and I want to cancel it / I want to sign a power of attorney or advanced health care directive. I feel like someone is pressuring me about money and I would like some advice. I recently signed papers related to my finances or estate, but I am not sure what they say. I have questions or concerns about reviewing or preparing estate planning documents. I have another money-related problem (not indicated above).

5 of 6: Abuse & neglect concerns

I do not feel safe at home. I believe I, or someone in my care (for example, a grandchild) may be in imminent physical or emotional danger. My basic needs are not being met by a person who promised to take care of me (being fed, bathed, clothed, etc.). I have another fear or concern about my safety.

6 of 6: Other concerns

In addition to any problems you have indicated above, do you have any other concerns about your situation now?

Yes

No

UNSHELTERED BRANCH LOGIC

Please select at least one option below

2 of 6: Government benefits, income, consumer debt

I avoid calls from debt collectors / I cannot pay my debts / I want the calls to stop and I am on a small and fixed income (Social Security Retirement, SSI, GA, etc). I have Social Security / SSI / Disability Income that has stopped or decreased. I got a letter from the County that says it will stop giving me / I am not eligible for food stamps, Medi-Cal, General Assistance, CalWORKs, etc. I am having problems with my pension -- I believe I earned a pension, but cannot locate it / am having problems with receiving pension payments. I have another problem or concern related to my income, benefits, or debt.

3 of 6: Financial exploitation

I signed a power of attorney (financial decisions) or advanced health care directive (health decisions) and I want to cancel it / I want to sign a power of attorney or advanced health care directive. I feel like someone is pressuring me about money and I would like some advice. I recently signed papers related to my finances or estate, but I am not sure what they say. I have questions or concerns about reviewing or preparing estate planning documents. I have another money-related problem (not indicated above).

5 of 6: Abuse & neglect concerns

I do not feel safe at home. I believe I, or someone in my care (for example, a grandchild) may be in imminent physical or emotional danger. My basic needs are not being met by a person who promised to take care of me (being fed, bathed, clothed, etc.). I have another fear or concern about my safety.

6 of 6: Other concerns

Yes No

Terms & Submit

Please review and confirm before submitting

I confirm that the information I have provided is true to the best of my knowledge.

I consent to LSNC collecting and using my information for the purpose of providing legal services or referral.

By checking these boxes and clicking submit, you acknowledge that LSNC may review your responses and contact you for further information. This submission does not create an attorney-client relationship until LSNC confirms representation.