Family Defense Intake Form

If you are a parent or guardian with a case involving Child Protection Services and are in need of an attorney, please fill out this form and we will be in contact with you.

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Request for Family Defender

If you are a parent or guardian with a case involving Child Protection Services and are in need of an attorney, please fill out this form and we will be in contact with you.

Your Information

First Name *

Middle Name

Last Name *

Email

Cell phone

Address

Address 2

City

State Select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Country

Case Information

Number of Children Removed *

Relationship with Children *

Mother Father Guardian

Other Parent's Name *

County * Select... Adams Alcorn Amite Attala Benton Bolivar Calhoun Carroll Chickasaw Choctaw Claiborne Clarke Clay Coahoma Copiah Covington DeSoto Forrest Franklin George Greene Grenada Hancock Harrison Hinds Holmes Humphreys Issaquena Itawamba Jackson Jasper Jefferson Jefferson Davis Jones Kemper Lafayette Lamar Lauderdale Lawrence Leake Lee Leflore Lincoln Lowndes Madison Marion Marshall Monroe Montgomery Neshoba Newton Noxubee Oktibbeha Panola Pearl River Perry Pike Pontotoc Prentiss Quitman Rankin Scott Sharkey Simpson Smith Stone Sunflower Tallahatchie Tate Tippah Tishomingo Tunica Union Walthall Warren Washington Wayne Webster Wilkinson Winston Yalobusha Yazoo

Next Court Date

Is your child in CPS custody? *

Yes No

Child

Child 1 Remove

Name

Child First Name *

Child Last Name *

Date of Birth *

MYCIDS/UCID

Placement at Referral

Foster Care Group Home Relative/Fictive Kin-In CPS Custody Relative/Fictive Kin-Not in CPS Custody

Date of Custody

+ Add Child

Household Information

Client Race

White/Caucasian Black/African American Hispanic American Indian/Alaska Native

Who all lives in the house with you? *

Current Employment Status *

Full Time Employed Part Time Employed Unemployed Disabled Retired Incarcerated

Have you ever qualified for free legal assistance? *

Yes No

Estimated Monthly Income *

Current Concerns

What are your goals for your case? Do you want your children home? Or placed with a relative or friend? How can we help you achieve these goals? *

Is there anything else you would like for us to know? *

How did you hear about us?

Let us know where you learned about our office. Select... Google or another search engine I was referred by a friend I was referred by an attorney or law enforcement