Intake Form

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 for Low Wage Workers (wrongful dismissal, employment standards, EI)None of the above

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 or Employed

Does your partner/spouse have an income? If yes, what is the monthly amount?YesNo

First language:EnglishOther

Interpreter required:YesNo

Gender IdentityFemaleMaleAgenderTransgender FemaleTransgender MaleOther

Ethno-racial identification:Aboriginal/indigenous (inside or outside North America)White/Caucasian (North America or other)Latin/AmericaAsian (South, Southeast, West, Filipino, Chinese, Korean, Japanese)Middle Eastern (Arab, Other)African Ancestry (North American, Caribbean, Latin American, European, Continental-North/South/East/West Africa, Somali; or Mixed racial heritageOther