New Client Questionnaire

To qualify for our free legal service, you need to be age 60 or older and have a monthly household income that is:

  • Less than $1,800, if you are single, or
  • Less than $2,400, if you are married.

To determine if you or the person you are representing qualify, please answer the questions below.  All of the information you give us will be kept confidential.  If you do not know the answer to a particular question, don’t worry. You can call us later with the information.  Do not send us any confidential or sensitive information.  We have not agreed to represent you at this time.   Being eligible for our free services is not a guarantee that we will meet with you. 

If you do not wish to fill out the online form, you may print out this questionnaire, and  e-mailfax or mail it.  You may also call 336-758-5061 and ask us to mail you the Eligibility Questionnaire.





Elder Law Clinic - Client Application




Elder Law Clinic - Client Application







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  • If you filled out this questionnaire for the person named above, please give us the following information about yourself.












































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