ORPC Preventive Legal Services Referral

The ORPC is providing legal services to indigent parents residing in Jefferson County. If you are a parent who has unmet legal needs that are affecting your family’s stability or safety, fill out this short questionnaire to determine your eligibility for legal support. If you are a professional working with the family, you may assist the parent to fill out this questionnaire or obtain consent to make this referral. An ORPC advocate will reach out to the referred parent within 48 hours.

1. Date of this referral: * +

2. Parent's First and Last Name: *

3. Parent's Date of Birth: * +

4. In which county does the parent reside? *

5. Parent's phone number (if unknown, write "unknown"): *

Can we safely text this number? *

Yes

No

Unknown

Can we safely leave a voicemail at this number? *

Yes

No

Unknown

6. Parent's Home Address (if unknown, write "unknown"): *

Can we safely send mail to this address? *

Yes

No

Unknown

7. Parent's email address (if unknown, write "unknown"): *

8. If you are assisting with this form, please include your information here:

Name:

Agency/Title or Relationship:

Phone:

Email:

.....

9. For open child welfare cases, what is the parent's assigned Client ID #, if known:

And what is the Case ID #, if known:

10. For open TANF or benefits cases, what is the parent's CBMS ID #, if known:

11. Which legal Issues does the parent have? Please check all that apply, even if you are unsure: *

If you chose "Other", please contact Jill Cohen at either 303-731-8750

or jcohen@coloradoorpc.org for more information.

12. Are the identified legal needs time sensitive? Examples include a scheduled court appearance or an eviction notice:

Yes

No

If yes, what is the date? * +

Please explain so we can respond in a timely manner: *

13. Does the parent qualify for or receive any income-based public benefits like Medicaid, WIC, SNAP, Public Housing, or TANF? *

Yes

No

Unknown

14. How many adults (18+) and children (under 18) reside in the parent's home? (if unknown, please write "unknown") *

	.
Adults	.
Children	.

15. What is the approximate household income? (Parent and adults who contribute to support of the home, excluding roommates)

16. What are the names of other adults who are helping to raise the child and/or are residing in the home (for the purpose of assigning an appropriate attorney)?

An ORPC advocate will contact the parent to discuss their eligibility for this preventive legal services program. The ORPC advocate will confirm eligibility, explain the process, and answer questions.

If a parent does not receive a response within 48 hours, or if there are further questions, please call 303-731-8770 or e-mail intake@coloradoorpc.org.