Beacon Law Intake

Thank you for your interest regarding Beacon Law's services. Before you continue with the application, we would like to note the legal issues with which we are able to assist and issues with which we cannot assist.

In general, our legal services include:

- ID Restoration including but not limited to resolving driver's license holds, replacement of immigration documents, and name change (for purposes of obtaining ID)

- Clearing Criminal History (expunctions and nondisclosures)

- Social Security Disability Appeals

- Limited Family Law (uncontested pro se divorce and child support modification)

- Housing Law including evictions

- Limited Wills & Estates (small estate affidavits, medical directives, medical and statutory powers of attorney, wills if you own real property)

We DO NOT assist with criminal representation above a Class C misdemeanor (i.e., traffic ticket), criminal appeals, contested divorces, child custody matters, protective orders, small claims and other lawsuits, employment discrimination, foreclosures, adjustment of immigration status, and the probate of wills or estates.

If you require assistance with these issues, you should contact Lone Star Legal Aid at (713) 652-0077 or Houston Volunteer Lawyers at (713) 228-0735.

Dependents
Do you have any people living with you that depend on you for financial support?*

YesNo
Household Size (including yourself)*

List the name, age and relationship to you for each person living with you that you support.

Monthly Household Income

Please enter total income for all contributing members of your household. A household consists of the people living with you who depend on you for financial support or are supporting you.
Employment Status*

Part Time EmployedFull Time EmployedUnemployedDisabledFull Time Student
Work Wages*
Total per month
Unemployment*
Total per month
Food Stamps/SNAP*
Total per month
Public Housing Assistance*
Total per month
Child/Spousal Support*
Total per month - Do not enter support you pay
SSI/SSDI/VA Disability*
Total per month
Retirement/Pension*
Total per month
Total Monthly Income

Assets
Do you own a house?*

Yes, with a mortgageYes, without a mortgage (fully paid off and in your name)No

Assets
What is the current value of your house?*

Assets
Do you own any vehicles, in your name? (If both a paid off vehicle and making payments applies to you, choose the "my car is paid off" option)*

Yes, with a car paymentYes, my car is paid offNo

Answer the following for ONLY vehicles that are fully paid for AND in your name.
Vehicle 1 - Year/Make/Model*
Vehicle 1 - Current Value*
Vehicle 2 - Year/Make/Model
Vehicle 2 - Current Value
Vehicle 3 - Year/Make/Model
Vehicle 3 - Current Value

Assets
Do you have any checking or savings accounts?*

YesNo

What is the current balance of your checking and/or savings accounts?*

Monthly Expenses
Mortgage/Rent*
Utilities*
Gas/Water/Electricity/Phone/Cable/Internet
Food*
Total including SNAP benefits plus out of pocket food costs
Child Care*
Car Payment/ Insurance*
Gas/Bus Fare/Tolls*
Attorney's Fees*
Health/Life Insurance Premiums*
Medical Expenses*
copays, prescriptions, etc.
Clothing/Laundry*
Other Misc. Personal Expenses*

Legal Needs Assessment

ID Restoration
1. Do you need to obtain a Texas Driver's License or Identification Card?*

YesNo
2. Are you aware of any outstanding Class C (traffic) tickets, warrants or anything else that could cause a hold on your Texas Driver's License?*

YesNoNot Sure

Are there any issues with your birth certificate (i.e. different name, misspelling, etc.) preventing you from obtaining a Texas ID or Driver's License?

YesNo
If you need assistance regarding your driver's license for something other than tickets or a name change, please explain what assistance you need.

Legal Needs Assessment

Sealing Criminal History
1. Have you ever been arrested in Texas and would you like to see if anything is eligible to be sealed on your criminal record?*

YesNo

Legal Needs Assessment

Public Benefits
1. Have you received a denial of a Reconsideration you filed for your SSI or Social Security Disability application? If the denial was in the last 60 days, we may be able to help

YesNo

Legal Needs Assessment

Family Law
1. Do you need to file for divorce?*

YesNo

Do you believe that your spouse will agree to the divorce?*

YesNoNot Sure
Do you know where your spouse lives?*

YesNo
If you have minor children, do you have a support order already in place?*

YesNoWe do not have any minor children

Legal Needs Assessment

Landlord/Tenant
1. Are you currently in a lease and facing possible eviction?*

YesNo

Please explain your housing situation.

Legal Needs Assessment

Other Legal Needs
If you have additional legal needs that were not addressed in this application, please explain in the box below. *We are not able to assist with active criminal cases or appeals.*

Authorization for Release of Information

It is often the case that applicants and clients of Beacon Law are not able to maintain consistent means of communication. Should it be necessary, you may authorize employees of Beacon Law to communicate with a designated friend or relative regarding your case. If you would like to authorize us to speak to another individual regarding your case, please complete the information below. This authorization is revocable at any time by written or verbal notice and does not constitute a violation of attorney/client privilege or breach of confidentiality.
Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
Email
example@example.com
Address

Street Address

City State

Zip Code

Authorization for Release of Information to Beacon Service Providers

This agreement is for legal services with Beacon Law, a program of The Beacon. The information you submit will remain confidential within Beacon Law, unless you authorize us to share it. In some cases, we may determine that applicants could benefit from additional services that The Beacon has to offer, such as case management or housing assessment, but we can only refer you for services with your permission. PLEASE NOTE: You can revoke this authorization, if you choose to opt-in, at any time by submitting a written request to Beacon Law or by speaking with an employee of Beacon Law and telling them you would like to revoke your authorization. You can contact Beacon Law by email (info@beaconlaw.org), phone (713-220-9780), or mail (P.O. Box 53958, Houston, TX 77052). PLEASE NOTE: This authorization does not violate attorney-client privilege or constitute a breach of confidentiality.
Choose One

Yes, I would like Beacon Law to share my information with other employees of The Beacon, including, but not limited to, case managers or housing assessors.No, I do not want Beacon Law to share my information with any employees of The Beacon.

Acknowledgement
Signature

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