Web Contact Form – Waterloo Region Community Legal Services

First and Last Name *

Date of Birth (DD/MM/YY) *

Phone Number *

Email Address *

Do you consent for us to contact you by e-mail? *

Yes
No

Street Address *

Unit Number (if applicable)

City *

Postal Code *

Do you identify as First Nation (Status or Non Status), Metis or Inuit? *

Yes
No

If yes, would you like to be contacted by the Indigenous Justice Coordinator to learn about additional services?

Yes
No

Do you require any accommodations? (e.g. hearing impairment, language interpretation, e-mail only, etc.)

What is your primary source of income? *

What is your total household income (e.g. spouse/partner's income, employment income, pensions, inheritances, etc…)? *

If you selected employment, please indicate your family size. *

What area of law do you need assistance with? *

If you need assistance with Housing law, please provide the name of your landlord. If you DO NOT need assistance with Housing law, please type: N/A. *

Brief description of your issue *

DISCLAIMER

We reserve the right to request your most recent Notice of Assessment at any time to verify your income and eligibility.

Email *