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All information collected is strictly confidential. Please allow up to three business days for a member of our staff to follow up. Urgent legal matters will be prioritized. If you do not hear from us within three days, call 416-531-7376.
Given Name(s)
Family Name(s) *
Date of birth
PronounsShe/herHe/himThey/themOther
Other
Email
Email CommunicationsYes, you can contact me by email.
Phone
Voicemail OK?Yes, you can leave voicemails at this number.
Is there a good time to reach you?
Is there anything else you need to tell us about how to best contact you?
If you are at no current fixed address, please enter the closest intersection to your current location.
OntarioBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutAlbertaPrince Edward IslandQuebecSaskatchewanYukon
We can only help people with low incomes. However, if your income is too high, we may still be able to provide you with summary advice and discuss referral options.
What is your main source of family income?EmploymentOntario 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
Number of Adults in the Family
Number of Children
Approximate Monthly Income*
This information does not impact whether you receive assistance from us, and is only collected to help us better understand the communities we serve.
Gender Identity—Please choose an option—FemaleMaleAgenderTransgender FemaleTransgender MaleOther
Other (specify):
Sexuality—Please choose an option—Gay/LesbianHeterosexualBi-sexualQueerTwo SpiritedOther
Ethno-racial Identification * —Please choose an option—Aboriginal/Indigenous (inside North America)Aboriginal/Indigenous (outside North America)African Ancestry – North AmericanAfrican Ancestry – CaribbeanAfrican Ancestry – Latin AmericanAfrican Ancestry – EuropeanAfrican Ancestry – Continental – North AfricaAfrican Ancestry – Continental – South AfricaAfrican Ancestry – Continental – East AfricaAfrican Ancestry – Continental – West AfricaLatin AmericanAsian – South AsianAsian – Southeast AsianAsian – West IndianAsian – FilipinoAsian – ChineseAsian – KoreanAsian – JapaneseMiddle Eastern – ArabMiddle Eastern – OtherWhite/Caucasian – North AmericanWhite/Caucasian – OtherUnknown/Choose not to identifyOther or Mixed Racial Heritage: Specify
Preferred Language
First LanguageEnglishOther
Interpreter RequiredYesNo
Special Needs/Accommodation Required
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 (denied, benefits cut off, overpayment)OW – Ontario Works (denied, benefits cut off, overpayment)CPP – Canada Pension Plan (retirement benefits or CPP disability benefits)ImmigrationEmployment Law (wrongful dismissal, employment standards, EI)OtherNone of the above
It is very helpful for us to have a brief description of the type of problem being experienced.
Please attach copies of any documents relating to the problem. For example, an eviction notice or a letter from Ontario Works.
Referring Agency (if an agency is supporting a client in completing this form)
Referring Staff Person (if an agency is supporting a client in completing this form)
