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* 1. Name

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* 2. Address:

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* 3. Phone Number:

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* 4. Email Address: 

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* 5. Do you have any children?

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* 6. Do you have a domestic marriage contract? 

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* 7. Do you have an open court file?

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* 8. Is there a history of any of the following:

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* 9. What is your current marital status:

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* 10. What are the issues you wish to address at your visit?
(Please pick three and rate the issues in order of priority)

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* 11. Please provide a brief of summary of your issue(s):

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* 12. What is your current status in Canada?
Please note: Hope 24/7 Staff and affiliates will not disclose your immigration status without your consent to anyone, for any reason, at any time. 

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* 13. Has a physical copy of your identification been provided to Hope 24/7 Staff or by Valerie Yap prior to your meeting? 
Please note: A form of valid photo identification must be presented to VALERIE YAP, BARRISTER & SOLICITOR. at the time of your visit. 
For the purposes of the Law Society of Ontario's identification verification guidelines, Valerie Yap, Barrister & Solicitor will retain a copy of your identification for no longer than six (6) years, and thereafter, the identification will be destroyed.  

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* 14. I consent to the Feminist Collective chaired by HOPE 24/7 to collect, use or disclose my personal and financial information for the limited purpose of obtaining services from HOPE 24/7.
I further agree the disclosure of my personal and financial information for the limited purpose of obtaining services VALERIE YAP, BARRISTER & SOLICITOR. I understand that in providing this consent, the Feminist Collective chaired by HOPE 24/7 will not sell, barter or lease personal information it obtains from me to third parties. I also understand that a physical copy of my identification will not be kept on file by Hope 24/7. 

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* 15. I consent to Valerie Yap, Barrister & Solicitor sharing minutes/details of my meeting with her with my Hope 24/7 clinician: Please select YES/NO
Note: Selecting no will not affect your eligibility to receive service. 

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* 16. Appointment times are once per month on Mondays, between 12-6 pm.
The next on-site Legal Clinic Date is Monday, October 16th, 2023.
Please select your preferred appointment time from the options below. 

Please Note: You will be contacted to confirm your appointment time. Indicating your preferred appointment time on this form will not guarantee an appointment for that timeslot. You will receive an email or follow up phone call confirming your appointment. Appointments run from 45 minutes - 1 hour.

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