African Nova Scotian Justice Institute - Intake Form
Please fill in your details.
First name
Last name
Email
Phone Number
Address
Additional Info
Date of Birth
Gender
Preferred Pronouns:
Marital Status:
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Single
Married
Common-law
Separated
Divorced
Widowed
Status in Canada:
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Canadian Citizen
Permanent Resident
Temporary Foreign Worker
Refugee
Other
If you are not a Canadian Citizen, please indicate your country of origin:
Arrival date to Canada:
Self-Identification:
I self-identify as Black/of African heritage or descent
I self-identify as African Nova Scotian
I self-identify as Indigenous (inside or outside North America)
I self-identify as a member of the queer community/2SLGBTQIA+
I do not self-identify with any of the groups above or choose not to self-identify
Community attached to:
First language:
Interpreter required?
Yes
No
Special Needs/ Accommodations Required:
69
Phone Number
Address
Alternate phone number
Preferred method of contact:
Landline phone
Cell Phone
Text
Email
Are you currently in jail? If, so what institution?
Who do you live with?
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Partner
Parent/Guardian
By Myself
Other
Their names and phone numbers:
Areas of Law
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Criminal
Family
Human Rights
Policing Complaint
Notes:
Court Information/Court Location (if applicable)
How did you hear about the African Nova Scotian Justice Institute?
Referred by an organization (please mention below)
Referred by an individual (please mention below)
Media (social media, radio, advertisements)
Google search
Other
Other referral
Next Court Date:
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If you currently have a lawyer, please name them below:
African Nova Scotian Justice Institute
Intake Form
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