ICADV LEGAL SERVICES REFERRAL FORM

ICADV LEGAL SERVICES REFERRAL FORM REV. 10/01/16 Referred by: Organization: Phone Number: Email: Circle appropriate title: IMPD Coordinator / Family Advocate / Extended Support Advocate / Other DATE: Updated on date: CLIENT/SURVIVOR: Please complete all information. Put N/A if it does not apply First Name Middle Name Last Name (If 2 last names, please include both) Gender Ethnicity DOB Age SSN Address- INCLUDING ZIP Is it safe to send mail to this address? YES [ ] NO [ ] Mailing Address (if different than above) Is it safe to send mail to this address? YES [ ] NO [ ] Phone Number [cell or home] Is this a safe number? YES [ ] NO [ ] Secondary Number [cell or home] Is this a safe number? YES [ ] NO [ ] Marital Status: Single [ ] Married [ ] Divorced [ ] Legally Separated [ ] E-mail Address: Does Client have disabilities? [ ] YES [ ] NO Is this a safe email? YES [ ] NO [ ] Does Client live in a rural area? [ ] YES [ ] NO Immigration Status (if any) Country of Citizenship Language(s) spoken: Race/Ethnicity [ ] Unknown [ ] Caucasian [ ] Black/African American [ ] Hispanic/Latina [ ] Asian [ ] American Indian/Alaskan Other (voluntary only): [ ] Limited English [ ] Deaf/Hearing Impaired [ ] Seeking Asylum/Immigration Relief OFFENDING PARTY: Please complete all information (for a conflict check). Put N/A if it does not apply First Name Middle Name Last Name (If 2 last names, please include both) Address - INCLUDING ZIP SSN Gender Ethnicity DOB Age Relationship to applicant (Spouse, boyfriend, etc.) Immigration Status (if any) Country of Citizenship Language(s) spoken: ARE THERE ANY COURT DATES OR DEADLINES? Date: Time: County: If immigration is an issue or client is not a U.S. citizen, please complete the following. Country of Citizenship: Immigration Status (if any): Cause No: Type of case: Is spouse a U.S. citizen or legal resident? Yes/N Do you have an attorney? [ ] YES [ ] NO If yes, who? Does opposing party have an attorney? [ ] YES [ ] NO If yes, who? Have you previously consulted with an attorney? [ ] YES [ ] NO If yes, when, where and what was the outcome?

Participant Agreement ICADV's Legal Resource Project The purpose of this document is to provide information to you about receiving legal help from the Indiana Coalition Against Domestic Violence, to clarify our responsibility to you and your responsibilities to us in your case. 1. Safety Planning - In some situations, taking legal action can increase your danger in the short term. Please be sure that you develop a personalized safety plan with your victim advocate. Revise your safety plan as things change with the person who stalked, threatened or used violence against you. 2. Your Right to an Interpreter - You have a right to an interpreter if you need one, for all of your meetings with your advocate, attorney and at court. If you need an interpreter, tell your attorney and your advocate. ICADV can assist in getting you an interpreter for meetings with your attorney and time at court with your attorney before hearings. The court is responsible for providing an interpreter for your court hearings. 3. Your Right to an Advocate - You have a right to receive advocacy and support services throughout your case. If for some reason you are not being helped by an advocate throughout your case, please contact Kerry at ICADV by phone at 317-917-3695 ext. 109 or kbennett@icadvinc.org. 4. Your Right to Understand Your Case - You have a right to understand what is going on with your legal case, and the documents related to it. Never sign anything or agree to anything until you understand it. If you don't understand something, tell your attorney and advocate, and ask that they help by providing more information. 5. Change in Financial Situation- If your income level changes and you become significantly over income for eligibility for our services, you may be asked to reimburse ICADV or your attorney at a rate of $75 per hour for the services you received. If your financial situation changes such that it would potentially will put you over income eligibility, please let your attorney know. You may be asked to sign an agreement regarding this. This allows us to stretch the limited dollars we have for other survivors with no assets or limited income. Otherwise, you should never be asked to pay your attorney. If you are asked Page 1 of 3

to pay your attorney, please contact Kerry at /CADV immediately. 6. Your Responsibilities During Your Case - Be honest with your attorney. Your attorney needs to know everything that may be brought up in your case in order to effectively represent you. Gather information needed for your case. If your attorney asks for records such as police reports, medical records, school records, etc. please gather and provide those as quickly as possible. Return calls to your advocate and attorney promptly. Follow your attorney's guidance and advice. He/she has been retained to represent you to get the most benefit possible from your legal action. Please follow any advice you receive. 7. Concerns/Complaints - If you have any concerns about your case, please speak with your advocate. If you do not feel that you are being properly assisted through the project, or you are having difficulty reaching your attorney or advocate, please call the project director, Kerry Hyatt Bennett, at 317-917-3685 ext. 109. Please do not file any action on your own during the time you are represented by an attorney through the project. This will cancel the program's commitment to provide legal assistance to you. If you feel an action is needed in your case, talk with your attorney. If you do not agree with your attorney or cannot reach him or her, please contact the project director, Kerry Bennett at 317-917- 3685 ext. 109. 8. Grant Funding - This legal program is funded by grants. We generally will not accept cases we do not believe can be complete within the grant year. However, if your case continues beyond our grant year and we would lose grant funding it could be possible that our assistance might end before your case is completed. If there is a known risk of that, we would let you know. 9. Re-opening a case - When your case is over, we close your case with our program. However, we know that new issues can arise with abusers. If you have a new legal need (for example, the other party violates orders, files something new, you think you need to change your orders, or you have a completely new legal concern), please contact the advocate who referred your case in to us. If you are still financially eligible and we have funding that matches your legal need, we may be able to assist you in the new matter. Page 2 of 3

10. Dropping Your Case - If you decide not to go forward with your legal case, please let your advocate and attorney know. You are entitled to change your mind about what is best for you. If you do withdraw from your case, and later decide that you need legal assistance, please contact us again. If resources allow, we will do everything we can to assist you at that time. 11. Positive Results - Finally, if you are happy with the result of your participation in this legal assistance project, please let us know that, too. We continue to raise funds for these services, and testimonials from survivors about the positive impact of having an attorney can help us raise more support for this project. Along with this letter you should receive a survey where you can share feedback about the legal assistance you receive. You can mail those to the program director, Kerry Hyatt Bennett, at ICADV, 1915 W. 18th Street, Suite 200, Indianapolis IN 46202 or fax to 317-917- 3695, or email them to kbennett@icadvinc.org. My signature below confirms that I have read this document, or it has been read to me, and that any questions I have had have been answered, and that I understand and agree to the things required of me during my case. Client Signature Date Advocate Witness Signature Date We offer our best wishes for you as you work to rebuild a safer life. For more resources for survivors, you can visit www.icadvinc.org and click on Information for Survivors. If you will be using the internet, please be careful to use a safe computer, such as at the library or a trusted friend's house. Page 3 of 3

Referring Agency Agreement Indiana Coalition Against Domestic Violence Legal Resource Project: 2016 General 1. The program will follow program guidelines as explained in the training. 2. The program will use all the forms required when referring cases to ICADV's Legal Resource Project, including but not limited to the Release of Information Form, the legal needs assessment and the screening and referral sheet. All forms must be completed in their entirety. 3. The program will ensure that staff provide emotional support, on-going safety planning and court accompaniment (when possible) of all survivors who are assisted through the project. 4. The program will notify ICADV Legal Counsel if the survivor withdraws the case or if the program loses contact with the survivor. 5. The program will notify ICADV Legal Counsel if the survivor encounters difficulties or the advocate has concerns with the attorney. 6. The program will ensure that staff members assist survivors and attorneys in gathering all corroborating evidence and other information needed by attorneys to effectively represent survivors. 7. The program will seek technical assistance and support from ICADV as needed to provide effective advocacy. 8. The program agrees that it will refer cases directly to ICADV Legal Counsel for consideration and if accepted, ICADV will assign a participating contract lawyer to the case. Confidentiality t 9. We will secure a signed, time-limited, purpose-centered Release of Information form from each survivor prior to releasing identifying information to ICADV or attorneys in the project. Intrue emergencies, oral releases may be obtained and used; however, they must be followed by the execution of a written release as soon as possible. 10. For security reasons, all referrals will be sent by facsimile transmission to ICADV Legal Counsel at 317-917-3695, or email to ICADV Legal Counsel ( kbennett@icadvinc.org) 11. Referring programs will email ICADV Legal Counsel prior to faxing referrals at kbennett@icadvinc.org. 12. Project and case paperwork and information will ultimately be shared with assigned counsel through a secure cloud based case management system.

Referring Agency Agreement Indiana Coalition Against Domestic Violence Legal Resource Project: 2016 Executive Director Referring Agency Laura Berry, Executive Director Indiana Coalition Against Domestic Violence Date signed Date signed Referral for: Rural Immigrant Legal Project ICADV Satellite Attorney Program

ICADV LEGAL SERVICES REFERRAL FORM REV. 7/6/16 Referred by: Phone Number: Email: Circle appropriate title: IMPD Coordinator / Family Advocate / Extended Support Advocate / Other DATE: Updated on date: CLIENT: Please complete all information. Put N/A if it does not apply First Name Middle Name Last Name (If 2 last names, please include both) Gender Ethnicity DOB Age SSN Address- INCLUDING ZIP Is it safe to send mail to this address? YES [ ] NO [ ] Mailing Address (if different than above) Is it safe to send mail to this address? YES [ ] NO [ ] Phone Number [cell or home] Is this a safe number? YES [ ] NO [ ] E-mail Address: Is this a safe email? YES [ ] NO [ ] Secondary Number [cell or home] Is this a safe number? YES [ ] NO [ ] Does Client have disabilities? Does Client live in a rural area? Marital Status: Single [ ] Married [ ] Divorced [ ] Legally Separated [ ] Immigration Status (if any) Country of Citizenship Language(s) spoken: [ ] YES [ ] NO [ ] YES [ ] NO Race/Ethnicity [ ] Unknown [ ] Caucasian [ ] Black/African American [ ] Hispanic/Latina [ ] Asian [ ] American Indian/Alaskan Other (voluntary only): [ ] Limited English [ ] Deaf/Hearing Impaired [ ] Seeking Asylum/Immigration Relief OPPOSING PARTY: Please complete all information (for a conflict check). Put N/A if it does not apply First Name Middle Name Last Name (If 2 last names, please include both) Address - INCLUDING ZIP SSN Gender Ethnicity DOB Age Relationship to applicant (Spouse, boyfriend, etc.) Immigration Status (if any) Country of Citizenship Language(s) spoken: ARE THERE ANY COURT DATES OR DEADLINES? Date: If immigration is an issue or client is Time: not a U.S. citizen, please complete the following. County: Country of Citizenship: Immigration Status (if any): Cause Is spouse No: a U.S. citizen or legal resident? Yes/N Type of case: Do you have an attorney? [ ] YES [ ] NO If yes, who? Does opposing party have an attorney? [ ] YES [ ] NO If yes, who? Have you previously consulted with an attorney? [ ] YES [ ] NO If yes, when, where and what was the outcome?

ICADV LEGAL SERVICES REFERRAL FORM (Page 2 of 3) All children and/or others living with you: (ESPECIALLY NOTE ALL CHILDREN BETWEEN CLIENT AND OPPOSING PARTY) Name Gender Date of birth Relationship to Client Relationship to Opposing Party INCOME: Do you work? [ ] YES [ ] NO If yes, where? Monthly income (from all sources): Your monthly housing/rent payment: Your monthly child care payment (if any): Opposing Party s monthly income: Opposing Party s Employer: Do you receive public benefits? [ ] YES [ ] NO TANF? [ ] YES [ ] NO WIC? [ ] YES [ ] NO $ amount: $ amount: Food Stamps? [ ] YES [ ] NO $ amount: Other? [ ] YES [ ] NO Source: $ amount: Type of Legal Assistance Needed: Divorce Custody Child Support Paternity (please circle all that apply) Immigration Bankruptcy Protective Order Other (please explain): Brief Description of the Problem: Other Legal Matters/Court Cases/Hearings Pending: Does the client have access to transportation to attend legal appointments and/or hearings? SAFETY PLAN INFORMATION / DISTRIBUTION- MUST BE COMPLETED BY ADVOCATE Safety Plan distributed by: Date:

ICADV LEGAL SERVICES REFERRAL FORM (Page 3 of 3) Type of Abuse: (check as many as apply) [ ] Physical [ ] Verbal [ ] Emotional [ ] Sexual [ ] Financial [ ] Stalking [ ] Other (explain) DETAILS: (Please be as specific as possible. ALL INFORMATION IS STRICTLY CONFIDENTIAL AND FOR CASE REVIEW PURPOSES ONLY. I authorize that this referral is being made to the legal services department of ICADV. All of the information I provided on this form is true to the best of my knowledge. Applicant Signature Date Advocate/Witness Date #

ICADV LEGAL SERVICES REFERRAL FORM (Page 2 of 3) All children and/or others living with you: (ESPECIALLY NOTE ALL CHILDREN BETWEEN CLIENT AND OPPOSING PARTY) Name Gender Date of birth Relationship to Client Relationship to Opposing Party INCOME: Do you work? [ ] YES [ ] NO If yes, where? Monthly income (from all sources): Your monthly housing/rent payment: Your monthly child care payment (if any): Opposing Party s monthly income: Opposing Party s Employer: Do you receive public benefits? [ ] YES [ ] NO TANF? [ ] YES [ ] NO WIC? [ ] YES [ ] NO $ amount: $ amount: Food Stamps? [ ] YES [ ] NO $ amount: Other? [ ] YES [ ] NO Source: $ amount: Type of Legal Assistance Needed: Divorce Custody Child Support Paternity (please circle all that apply) Immigration Bankruptcy Protective Order Other (please explain): Description and History of the Problem: Please add additional sheets if necessary and attach ALL LEGAL DOCUMENTS Other Legal Matters/Court Cases/Hearings Pending including cause numbers: Does the client have access to transportation to attend legal appointments and/or hearings? SAFETY PLAN INFORMATION / DISTRIBUTION- MUST BE COMPLETED BY ADVOCATE

Safety Plan distributed by: Date: ICADV LEGAL SERVICES REFERRAL FORM (Page 3 of 3) Type of Abuse: (check as many as apply) [ ] Physical [ ] Verbal [ ] Emotional [ ] Sexual [ ] Financial [ ] Stalking [ ] Other (explain) DETAILS: (Please be as specific as possible. ALL INFORMATION IS STRICTLY CONFIDENTIAL AND FOR CASE REVIEW PURPOSES ONLY. I authorize that this referral is being made to the legal services department of ICADV. All of the information I provided on this form is true to the best of my knowledge. Applicant Signature Name in Print: Advocate/Witness Name in Print: Date Date Please attach all relevant legal documents