QELC Application Form


The Queen’s Elder Law Clinic can only provide pro bono legal services to clients with limited budgets who could not otherwise afford legal services. While we provide a broad range of legal services, there are some matters with which we cannot assist clients.

This form will be kept strictly confidential, and will only be seen by the Director of QELC and the student caseworkers. It will be used solely to confirm whether it is appropriate for QELC to provide you with legal services. We reserve the right to request further financial disclosure.

For more information, you can reach the Elder Law Clinic at 613-533-2102, or email us at qelc@queensu.ca.

 

Client Information:

Name:

Age:

Occupation:

Telephone:

Email:

Address:


Is the client physically and mentally able to visit the clinic at 303 Bagot Street, Fifth Floor, in downtown Kingston?
YesNo

 

File Information

What would you like QELC's help with?

For the situation you’ve described above, list any people or organizations with conflicting interests (i.e. if the client is a tenant, they might have a conflict with their landlord; if they're having financial trouble they might have a conflict with creditors or the bank, etc.):

Is there a date by which this situation must be resolved?

 

Financial Information

(Please provide detailed information. This information is strictly confidential.)

Household Income:

Savings:

Real Property (house(s), cottage(s), rental property, land):

Other significant assets:

Debts:

 

How were you referred to our clinic?

Know clinic member personally.
Referred by someone. Name:
Website.
Saw clinic advertisement or brochure. Where?
Other. (please explain)


I certify the foregoing information to be accurate and complete to the best of my knowledge.