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Office use only Received: Link sent : More info needed: Issue : Apt : Conflict : Petra :

We know people have been spending a long time on the phone waiting for an answer and this isn’t fair. We want to introduce an easier way of you applying for an appointment.

Please complete this form and email it to [email protected] and you will be contacted in the next 2 working days to confirm if you have an appointment.

You can also drop into our office on the ground floor of the Central London County Court, Thomas More building, Royal Courts of Justice Strand London WC2A 2LL 9.30am – 1pm and 2pm – 4pm and someone will assist you to complete this form. You can also phone us on 0203 475 4373 9.30am – 1pm if you want assistance completing this form or visit us at our main RCJ office 2pm – 4pm.

Please note drop in sessions are only to complete the assessment form, you will not be seen on the day but will be given an appointment if you are eligible.

1. Your contact details

Address:

Date of birth:

Gender:

Name of the other side:

Your Mobile phone:

Your phone number:

Your Email Permission to contact/leave message? Please complete box below to tell us how we can contact you.

2. What is your case about?

Money or a debt you owe Bankruptcy Money owed to you (we can help if you are a small business but not if you are a large business) A consumer problem Losing your home A problem with your neighbours An Anti-Social Behaviour Order (known as an ASBO) Personal Injury or a claim A claim made in court against you A claim you wish to make A Judicial review claim Application for permission to appeal Legal cost issues A probate claim you wish to make or contest Other (please state)

2.1 Please provide a brief description of what you are wanting legal advice about 3. Free legal advice

Have you had legal advice about this issue? Please circle which options apply

Yes a solicitor – please add details why no longer

You will need to bring a letter from your solicitor confirming you are no longer a client

Yes a barrister – please add details why no longer

Yes from another advice provider – CAB or Law Centre

Can you afford legal advice Yes/No

Please note our service exists to help people who cannot afford legal advice. If at any stage we think you are being represented or -you are able to instruct legal representation either through legal aid or privately we are likely to withdraw our service.

Are you in receipt of any benefits? Yes/No

4. What stage is your case at?

You haven’t taken any action yet You have taken initial action e.g. sent a letter You are preparing a claim form or defence form You have received a letter from the other side or the court You have received court papers You have been asked to comply with a direction You want to enforce an order You need help to stay proceedings You want to set aside an order You want to know how to comply with an order You need representation at a court You have a court hearing Other (please provide details) 5. Deadlines

Do you have any deadlines to meet or hearing dates – if so please state and if possible attach a scanned copy with your email.

6. Assistance

If you attend an appointment is there any assistance or additional help you need when you come to see us due to the following (please tick all that apply):

Mental health condition or learning difficulty Physical disability or health problem Low Income Lack of confidence with spoken or written English Do not have easy access to on-line services Are a victim of domestic violence Dependant on drugs or alcohol Child or young person Lone parent History of imprisonment Living in temporary accommodation with children Involvement with social services Need BSL signer Need interpreter – which language PSU/Emotional support Physical access Other – please state How did you hear about us? Please tick all that apply

Our website Another website Local Citizens Advice or Law Centre Personal Support Unit From the court From a Judge Other:

Thank you. Please submit this form to [email protected]

Completing this form does not mean you have an appointment. Forms will be reviewed at the end of the day and we will contact you if we are able to offer you an appointment. This will be within 2 working days.

We will contact you if we require any further information before making the appointment.

If you send any additional information to the email address it will not be read.