Sample Forms
October 2005
This form provides the legal staff with some basic information regarding the client: name, contact information, and a brief description of the identified legal need. At some sites, the referral form is accompanied by a release signed by the client allowing the legal staff to obtain medical records or to speak with the client's medical providers. At other sites, releases are signed only after intake interview, at which time the legal staff can determine what releases will be necessary in handling the case.
Client Intake Form (MLPC | Boston)
June 2006
This form provides a template for an in-depth intake interview, which allows the staff member at intake to organize as much of the information that is routinely collected as possible. Please note that this form was developed in
Child Supplemental Intake Form
Adult Supplemental Intake Form
Release of Information and Records Form (MLPC | Boston)
June 2007
This form allows the client to grant the legal staff permission to speak to his/her doctor and other agencies in order to gather information pertaining to the case. This form is traditionally completed at intake.
Release of Protected Health Information Form (MLPC | Boston)
May 2007
This form allows the client to grant the legal staff permission to view his/her protected health information as it pertains to the case. This form is traditionally completed at intake.
Legal Service Provider Activity Tracking Form (NERMLn)
October 2005
While the intake form gathers information that describes the situation of the client, this form may be used to record the specific activities of legal staff as they serve a client. Systematically collecting this information will help sites understand the staff resources that are required for different types of legal matters and also provide documentation of the many types of assistance (from case consultations to legal advice to full representation) that staff are providing.
Outcome Tracking Form (NERMLn)
October 2005
This form allows legal staff to document outcomes resulting from the provision of services. The focus here is on outcomes that are known to the program staff, such as receipt of a particular benefit or service. As a result, the data obtained will address proximal or short-term outcomes. Additional measurement tools will be required to connect these outcomes to ones that are more distal, such as effects on family stability or child health.
May 2007
This brief form can be completed at the time of case closing. It provides space to summarize the legal needs identified by the referring provider and legal staff, record action steps taken and summarize outcomes.
October 2005
Satisfaction is an important measure of quality of program activities and can be useful in making improvements to the delivery of services. This form may be used to gather feedback from clients following their involvement in the program.