General Intake Form:

Personal Information:

First  Name:                                                          

Last Name:                           

Address:                                                                

City:                                       

State:               

Zip:

Home Phone:                                        

Work Phone:                              

Cell Phone:                                          

Email:                                                                 

Preferred Method of Contact: 

Representation and Assistance:

Do you have an attorney?

Have you contacted others for assistance? If so, what other organizations have you contacted and what is the status of you claim with them?

Case Information:

When did this occur?                                                                      

Where did this occur?

Were there other witnesses/aggrieved parties/participants? Please include their names and contact information.

Please provide a concise summary of the events that have prompted you to contact the NYCLU Nassau. You may use additional room, but please limit your summary to one page.

Were you given any explanation for what happened?  If so, what was it? 

Why do you think this happened?

Have you done anything on your own to try to solve the problem (e.g. written letters, filed an appeal)?

What would you like the NYCLU Nassau to do for you?

Please mail or fax to:

NYCLU Nassau

Legal Intake

250 Fulton Ave. Ste. 514A

Hempstead, 11550