Request Family Law Help: Rose Haven Clinic

All information provided is confidential.

Please note the types of cases we CANNOT help with:

Adoptions
Dependency cases - DHS /CPS has filed a case and taken custody of a party's minor child
Delinquency - juveniles involved in criminal justice system
Guardianship
Immigration

About Your and Your Case

Is there anything else related to your case you want us to know? (If you marked "something else" above, please briefly describe the legal issue you need help with.) *

First Name *

Middle Name

Last Name *

Other Names Used (if any)

Your Pronouns *

Are you a registered Rose Haven guest? *

Have you you attended the Rose Haven clinic before? *

Yes

No

Email *

Phone

Can this number receive text messages?

Yes, send me info over text.

No, do not contact me over text.

May we call this number and leave a detailed voicemail?

Yes, calls and voicemails are okay.

Yes, but do not leave voicemails.

No, do not call my phone.

Mailing Address if available (Please include City, State, and ZIP)

Which most closely describes your gender? *

Woman

Man

Transgender Woman

Transgender Man

Non-Binary

Agender/I don’t identify with any gender

Gender not listed

Prefer not to state

Are you comfortable meeting with a male-presenting attorney? *

Translation: Do you need a translator for phone or video appointments? If so, which language? *

How would you describe your racial identity? *

Are you of Hispanic or Latino/a/e/x descent? *

Yes

No

Decline to state

Have you ever served in the armed forces? *

Yes

No

About The Other Party -

Answer this information about the other "side" of your case.
This might be your ex-partner, or soon-to-be ex-partner, or it may be the other parent of your child.

What is the *FULL NAME* of the other party in your case? *

Is there a history of domestic violence, abuse, or act of aggression by the opposing party? *

Yes

No

Are you afraid of the other party in your case? *

Yes

No

If known, which Oregon county is your case in? *

Do you have an existing or previous court case with your opposing party? *

Yes

No

Not Sure

If known, what is your case number?

List any upcoming court hearings or deadlines.

Grant Tracking Information: Income & Household Size

What is your household size? *

**Your household size is how many people live together in your home and share costs like rent, food, and bills. For example, you should include people you file taxes with or who you claim on your taxes. Count anyone who falls into these categories if you live with them more than 50% of the year and share financial resources with them or provide resources for them.

What is your monthly income? (Before tax) *

What is your yearly income? (Before tax) *

**You only need to provide the gross income that is available to you, but you must provide a number.**
*We will never share your personal information without asking you first.*

We will review your information to confirm that you are eligible to speak with an attorney. If you provided an email address, a confirmation of this submission will be sent there. Unless you hear otherwise, please plan to attend the next Rose Haven clinic. We look forward to assisting you!

Submitting this form does not create an attorney-client relationship.