LSNC Legal Risk Detector
1
WELCOME
2
APPLICANT
3
RENTER
4
OWNER
5
UNSHELTERED
6
Terms and Conditions
Welcome
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Your First Name:
Your Last Name:
Email:
Organization:
Advocates for Mentally Ill Housing (Placer/Nevada)
Amador Tuolumne Community Action
Brain Injury Coalition
Bayanihan Clinic
Butte County Adult Protective Services
Calaveras Mariposa Community Action Agency
City Of Davis
Clinica Tepati
Humboldt County DHHS - Public Health
Communicare
Davis Community Meals and Housing
Dixon Family Services
El Dorado County CommunityHealth Center
Empower Yolo
Empower Tehama
FRC - Tahoe Truckee
Fairfield Healthy Start Family Resource Center
FRC Sierra County
FRC in SL Tahoe
FREED Center for Independent Living
Fourth and Hope
Gathering Inn Homeless Shelter provider
HHSA (Yolo Health and Human Services Agency)
Hill Country Community Clinic
Imani Clinic
JVMC Clinic/Harm Reduction Services
La Clinica Vallejo
LSS Northern California (Shasta)
Lassen County HHSA
Lighthouse - Lincoln FRC
Lutheran Social Services of Northern California
NorCal 211
NorCal United Way
North American Mental Health Services
Nation's Finest (Resource Centers of America)
Mountain Valleys Health Centers
One Safe Place
Open Door Community Health Center
PSA2
Paul Hom Asian Clinic
Placer Independent Resource Services
RISE
Redding Pathways to Housing
Sacramento UC Davis Pediatrics
Sacramento County Health Center
Sacramento Vet Center
Sacramento LGBTQ Center
Shasta Community Health Center
Shasta County APS
Shasta County Housing Authority
Shasta County HHSA
Mercy Medical Center - Dignity Health Common Spirit
Shifa Clinic
Solano Workforce Development Board
Stonewall Alliance Center of Chico
TEACH, Inc.
Tehama County Department of Social Services
Turning Point
Ukiah
Vallejo Housing Justice Coalition
Waking the Village
Willow Clinic
Weave
Wind
Yolo Community Care Continuum
Yolo County Childrens Alliance
LSNC Office:
LSNC Fax:
Your password:
This single-use password allows you to access the encrypted PDF copy of this referral you will receive by email. Because we are unable to retrieve your single-use password, please choose a password you will remember.
Confirm password:
Please confirm your password.
Applicant's info
Please provide Applicant's contact information.
Applicant's first name:
Applicant's last name:
Age reported by applicant:
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?
Yes
No
Do you have any barriers to reaching legal services during normal business hours (8:30 a.m. to 5 p.m.)?
Yes
No
Do you have an email address?
Yes
No
Please provide a valid email
Click here to use address autocomplete (recommended).
Home street address:
Home city:
Home state:
Home zip:
Is your mailing address different?
Yes
No
Please provide a correct mailing address
Monthly household income?
Household size?
After inputting the Applicant's information above, please carefully select what type of housing the Applicant lives in.
Rents
Owns
Unsheltered
Previous
RENTER BRANCH LOGIC
Please select at least one option below
1 of 6: Housing
Regarding your housing, are any of these statement true?
I have a notice from my landlord that I need help with (example: 3 Day Notice to Pay Rent or Quit, Notice to Terminate Tenancy, etc.).
I was given papers that look like they are from the court.
My landlord will not make the repairs I have asked them to make.
I have a different housing-related problem.
Please provide any details to help us understand the housing problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I believe Applicant urgently needs help to address the problem(s) noted above.
2 of 6: Government benefits (income) and other income problems
Regarding your government benefits (income) and other income problems, are any of these true?
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 have a different income or benefits problem.
Please provide any details to help us understand government benefits problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I Believe My Applicant Urgently Needs Help To Address The Problem(s) Noted Above.
3 of 6: Financial exploitation
Regarding financial exploitation, are any of these true?
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 have questions or concerns about reviewing or preparing estate planning documents.
I have a different money-related problem.
Please provide any details to help us understand financial exploitation problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I Believe My Applicant Urgently Needs Help To Address The Problem(s) Noted Above.
4 of 6: Health care concerns
Regarding health care, are any of these true?
I cannot pay for my medication or medical care.
I cannot get the mental health care I need.
My health insurance or health plan denied a service/procedure/prescription my doctor said I need.
I have a problem with In-Home Supportive Services (IHSS).
My Medi-Cal (Partnership, Anthem, CA Health and Wellness, etc), Medicare, or other healthcare coverage has ended.
I am uninsured and need care.
I have a different healthcare-related problem.
please provide any details to help us understand health care problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I believe my applicant urgently needs help to address the problem(s) noted above.
5 of 6: Abuse & neglect concerns
Regarding your safety and rights, are any of these true?
I do not feel safe at home.
My basic needs are not being met by a person who promised to take care of me (being fed, bathed, clothed, etc.)
I have a different concern about my safety.
Please provide any details to help us understand abuse & neglect problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I Believe My Applicant Urgently Needs Help To Address The Problem(s) Noted Above.
6 of 6: Other concerns
In addition to any of the problems you marked above, do you have any other concerns you want to speak with a legal advocate about?
Yes
No
If yes, please describe other concerns
SUBMIT
Previous
OWNER BRANCH LOGIC
Please select at least one option below
1 of 6: Housing
Regarding your housing, are any of these statement true?
I have been unable to pay my mortgage and/or I have papers that say I owe a past-due balance on my mortgage and I am worried about foreclosure.
I own a mobile home or RV and I am having problems with park management.
I was given papers that look like they are from the court.
My home needs repairs and I can't afford to make them.
I have a different housing-related problem.
Please provide any details to help us understand the housing problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
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Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I believe Applicant urgently needs help to address the problem(s) noted above.
2 of 6: Government benefits (income) and other income problems
Regarding your government benefits (income) and other income problems, are any of these true?
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 have a different benefits or income related problem.
Please provide any details to help us understand government benefits problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I believe Applicant urgently needs help to address the problem(s) noted above.
3 of 6: Financial exploitation
Regarding financial exploitation, are any of these true?
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 have questions or concerns about reviewing or preparing estate planning documents.
I have a different money-related problem.
Please provide any details to help us understand financial exploitation problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I Believe My Applicant Urgently Needs Help To Address The Problem(s) Noted Above.
4 of 6: Health care concerns
Regarding health care, are any of these true?
I cannot pay for my medication or medical care.
I cannot get the mental health care I need.
My health insurance or health plan denied a service/procedure/prescription my doctor said I need.
I have a problem with In-Home Supportive Services (IHSS).
My Medi-Cal (Partnership, Anthem, CA Health and Wellness, etc), Medicare, or other healthcare coverage has ended.
I am uninsured and need care.
I have a different healthcare-related problem.
Please provide any details to help us understand health care problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I believe Applicant urgently needs help to address the problem(s) noted above.
5 of 6: Abuse & neglect concerns
Regarding your safety and rights, are any of these true?
I do not feel safe at home.
My basic needs are not being met by a person who promised to take care of me (being fed, bathed, clothed, etc.)
I have a different concern about my safety.
Please provide any details to help us understand abuse & neglect problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I Believe My Applicant Urgently Needs Help To Address The Problem(s) Noted Above.
6 of 6: Other concerns
In addition to any of the problems you marked above, do you have any other concerns you want to speak with a legal advocate about?
Yes
No
If yes, please describe other concerns
SUBMIT
Previous
UNSHELTERED BRANCH LOGIC
Please select at least one option below
1 of 6: Housing
Regarding your housing, are any of these statement true?
I am currently unsheltered, couch surfing, living in my car, or staying with friends/family and want information on housing resources.
I am trying to stay at a shelter but am having problems
It has been hard for me to find housing because of my criminal record.
I am currently unsheltered and I received a camping/sleeping outside ticket from law enforcement
I was given papers by a sheriff that say I have only a few days to move.
I have a different housing-related problem.
Please provide any details to help us understand the housing problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I Believe My Applicant Urgently Needs Help To Address The Problem(s) Noted Above.
2 of 6: Government benefits (income) and other income problems
Regarding your government benefits (income) and other income problems, are any of these true?
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 have a different income or benefit problem.
Please provide any details to help us understand government benefits problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I Believe My Applicant Urgently Needs Help To Address The Problem(s) Noted Above.
3 of 6: Financial exploitation
Regarding financial exploitation, are any of these true?
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 have questions or concerns about reviewing or preparing estate planning documents.
I have a different money-related problem.
Please provide any details to help us understand financial exploitation problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I Believe My Applicant Urgently Needs Help To Address The Problem(s) Noted Above.
4 of 6: Health care concerns
Regarding health care, are any of these true?
I cannot pay for my medication and/or medical care.
I cannot get the mental health care I need.
My health insurance or health plan denied a service/procedure/prescription my doctor said I need.
I have a problem with In-Home Supportive Services (IHSS).
My Medi-Cal (Partnership, Anthem, CA Health and Wellness, etc), Medicare, or other healthcare coverage has ended.
I am uninsured and need care.
I have a different healthcare-related problem.
Please provide any details to help us understand health care problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I Believe My Applicant Urgently Needs Help To Address The Problem(s) Noted Above.
5 of 6: Abuse & neglect concerns
Regarding your safety and rights, are any of these true?
I do not feel safe at home.
My basic needs are not being met by a person who promised to take care of me (being fed, bathed, clothed, etc.)
I have a different concern about my safety.
Please provide any details to help us understand abuse & neglect problem(s) selected above:
Community Partner, please select the most applicable statement from your point of view.
Applicant would like general information about the problem(s) noted above.
Applicant requests assistance to address the problem(s) noted above.
I Believe My Applicant Urgently Needs Help To Address The Problem(s) Noted Above.
6 of 6: Other concerns
In addition to any of the problems you marked above, do you have any other concerns you want to speak with a legal advocate about?
Yes
No
If yes, please describe other concerns
SUBMIT
Previous