Lex Dexter Legal Assistance Services
www.lexdexter.ca
Intake Form
Law Firm Intake Form
First Name
Middle Name
Last Name
Type of Client
Individual
Law Firm
Law Firm Name
Date of Birth
Email
Phone Number
Address
Address Line 1
Address Line 2
City
Province
Postal Code
What is your legal matter about?
Type of Legal Matter
– Select –
Provincial Offence(s) or Federal Contravention(s)
Summary Conviction Offence(s)
Small Claims
Human Rights
Immigration/Citizenship
Research & Drafting Support
Other
Describe your Type of Legal Matter/Area of Law
Opposing Party Information
Date of Incident (if this occurred over a period of time, put the most recent date it occurred and add more details below)
Courthouse (location) and Prosecutor (Federal or Provincial Crown/name of Municipality/name of Crown Corporation/name of private prosecutor)
What document did you receive from the officer who charged you?
Offence Notice (Part I)
Summons (Part I)
Summons (Part III)
Unsure/Other
Next Court Date (if known)
Description of Offence(s) or Reference to Section & Act for each Offence
Are you the Plaintiff or the Defendant?
Plaintiff
Defendant
Grounds of discrimination
race
ancestry
place of origin
colour
ethnic origin
citizenship
creed / religion
sex or pregnancy
sexual orientation
gender identity
gender expression
age
marital status
family status
disability
sexual harassment or solicitation in accommodation or at work
receipt of public assistance as applicant for housing
(employment only) record of provincial offence/contravention or criminal offence that was pardoned (i.e. it does not appear on a criminal record check anymore)
Association with a person identified above
Reprisal or threat of reprisal for ascertaining a right or refusing to infringe upon a right in the Human Rights Code
In what areas have you been discriminated against?
Services, Goods, or Facilities
Accommodation
Contracts
Employment / Workplace
Membership in a Vocational/Occupational/Trade Association, Union, or Self-Governing Profession
Who discriminated against you? (Name of person(s) and your relationship to them)
When were you served with the plaintiff’s claim?
What is your current status in Canada?
– Select –
Permanent Resident
Protected Person
Work Permit Holder (temporary resident)
Study Permit Holder (temporary resident)
Visitor Record Holder (temporary resident)
Temporary Resident Permit Holder
Visitor arrived within last 6 months without additional documentation (temporary resident)
Applicant for refugee protection in Canada, otherwise out of status
Out of Status in Canada (status expired in the last 3 months)
Out of Status in Canada (status expired more than 3 months ago)
Out of Status and subject to a Removal Order
Do you have any documents related to this matter?
Yes
No
Are there other details you would like to add?
How did you hear about us?
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