Family Law Self-Help Centers Statistical Reporting Form
Please take the time to complete the following questions. Do not provide your name or caseidentifying information. The information below will be used only to help the courts evaluate future program needs. 1. Please indicate your ethnic background (optional): ~ ~ ~ ~ ~ ~ ~ African-American Asian Caucasian Hispanic Native American Pacific Island OTHER: 5. Please indicate your primary language: ~ English ~ Spanish ~ Other:
FOR OFFICE USE ONLY: Type of Assistance Provided (check all that apply): ~ Telephone Assistance ~ Walk-in Assistance ~ Assistance with forms only ~ Mediation preparation ~ Parenting Plan review ~ Legal advice ~ Trial Preparation Assistance by Case Type: ~ Absolute/Limited Divorce ~ Adoption ~ Alimony ~ Child Support-Non IVD ~ Child Support-IVD Case No. ______________________ ~ Custody ~ Name Change ~ Paternity ~ Visitation ~ Domestic Violence Further Assistance Recommended: ~ Proceed Pro Se ~ Legal Services Provider ~ Lawyer Referral ~ Child Support Agency ~ Other: _____________________
2. Please indicate your gender: ~ Male ~ Female 3. How much money do the adults in your household earn per year (combined income of all adults): ~ $0 - $14,999 ~ $15,000 - $29,999 ~ $30,000 - $49,999 ~ $50,000 - $69,999 ~ $70,000 - $99,999 ~ $100,000 + 4. What is the highest level of education you completed?: ~ Less than High School ~ High School ~ Technical School ~ Some College ~ Bachelors Degree ~ Advanced Degree
Revised 1 May 2008