Lease Assistance Intake Form

A confidential intake for legal aid groups helping survivors of abuse get out of a rental lease. It records the person's situation, landlord details, safety concerns and basic demographic data.

Use this template

In the Claude connectors directory

Full name

First Name

Last Name

Current address

Street Address

City

State / Province

ZIP / Postal Code

What is your date of birth?

What is your relationship status?

Phone number

Is it safe to call you at the number above?

Yes No

What is the safest or best time to call you?

I am seeking release from my lease because I am a victim of:

Domestic violence Dating violence Sexual assault Stalking

I have experienced the following forms of abuse:

Approximate date of the most recent incident

What is the name of the person who abused you?

First Name

Last Name

Do you currently live with the person who abused you?

Yes No

Is the address above the one for the lease you want to be released from?

Yes No

If not, enter the address of the lease you want to be released from

Street Address

City

State / Province

ZIP / Postal Code

Landlord name/company

How much is your rent?

How many months are left on your lease?

Are you currently in eviction proceedings?

Yes No

Do you have a final protection order against the person who abused you?

Yes No

Are criminal charges pending against the person who abused you?

Yes No I don't know

Would you like to discuss seeking a protection order? (A final order can also help release you from your lease.)

Yes No

Household information

How many people live in your household? (including you and any children)

Demographic information (optional)

What is your gender?

Are you transgender?

What is your race?

Asian Black or African American Hispanic or Latino Indigenous White Multiracial Prefer not to say

I certify that the information provided is true.

Client signature

Sign here

Date signed by client

For staff use only

Staff signature

Sign here

Date

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