Client Information
First Name
Last Name
Middle Name
Date of Birth
Calculated Age (verify this value and enter it below in the Age field)
Age
Contact Information
Preferred Phone Type
Mobile Phone
Home Phone
Work Phone
Other Phone
Mobile Phone
Home Phone
Work Phone
Other Phone
Email
Eligibility
County where you live
Please select...
COUNTY NOT LISTED
Anderson
Bath
Boone
Bourbon
Boyd
Boyle
Bracken
Campbell
Carroll
Carter
Elliott
Fayette
Fleming
Franklin
Gallatin
Grant
Greenup
Harrison
Jessamine
Kenton
Lewis
Mason
Menifee
Mercer
Montgomery
Morgan
Nicholas
Owen
Pendleton
Robertson
Rowan
Scott
Woodford
County where your problem is
Please select...
COUNTY NOT LISTED
Anderson
Bath
Boone
Bourbon
Boyd
Boyle
Bracken
Campbell
Carroll
Carter
Elliott
Fayette
Fleming
Franklin
Gallatin
Grant
Greenup
Harrison
Jessamine
Kenton
Lewis
Mason
Menifee
Mercer
Montgomery
Morgan
Nicholas
Owen
Pendleton
Robertson
Rowan
Scott
Woodford
County where you live
Please select...
COUNTY NOT LISTED
Anderson
Bath
Boone
Bourbon
Boyd
Boyle
Bracken
Campbell
Carroll
Carter
Clark
Elliott
Estill
Fayette
Fleming
Franklin
Gallatin
Garrard
Grant
Greenup
Harrison
Jessamine
Kenton
Lawrence
Lewis
Lincoln
Madison
Mason
Menifee
Mercer
Montgomery
Morgan
Nicholas
Owen
Pendleton
Powell
Robertson
Rowan
Scott
Woodford
County where your problem is
Please select...
COUNTY NOT LISTED
Anderson
Bath
Boone
Bourbon
Boyd
Boyle
Bracken
Campbell
Carroll
Carter
Clark
Elliott
Estill
Fayette
Fleming
Franklin
Gallatin
Garrard
Grant
Greenup
Harrison
Jessamine
Kenton
Lawrence
Lewis
Lincoln
Madison
Mason
Menifee
Mercer
Montgomery
Morgan
Nicholas
Owen
Pendleton
Powell
Robertson
Rowan
Scott
Woodford
Are you a citizen of the US?
Yes
No
Are you a victim of violence?
Yes
No
What kind of violence are you experiencing?
Elder Abuse
Domestic Violence
Interpersonal Violence
Not Specified
If you do not see your county, please visit this link for service providers near you:
https://www.kyjustice.org/help-near-you
Legal Issue
Legal Issue Category
Do you need legal help because you have experienced interpersonal violence, stalking, domestic violence, or sexual assault?
Are you having problems with your housing?
Do you need help with a divorce, custody or visitation?
Are you seeking bankruptcy or being sued by a creditor?
Are you seeking help with a government benefit like SNAP, Medicaid, SSI, Medicare, etc.?
Are you seeking a criminal record expungement?
Do you want to change your name?
Do you have a problem with the IRS regarding overdue taxes?
Are you seeking a life planning documents like a will, living will, health care surrogate, etc?
If your problem is not listed, please describe below:
Consumer Legal Issues
Are you seeking a bankruptcy?
Are you being sued by a creditor?
Family Legal Issues (violence, stalking, DV, SA)
Is the person who is abusing or stalking you a domestic partner or spouse?
Have you been raped, sexually assaulted or abused by someone who is not a domestic partner or spouse?
Have you been threatened, abused, raped or stalked by someone you are or have been dating?
Family Legal Issue (divorce, custody, visitation)
Are you a victim of domestic violence needing help with a divorce?
Are you an unmarried victim of domestic violence who needs help with custody?
Other (please describe below)
Housing Legal Issues
Are you about to be evicted from your Section 8 housing?
Are you about to be evicted from a public housing unit?
Are you about to be evicted by a private landlord?
Is there a problem with the title on the home where you live?
Are you a home owner in foreclosure?
Are you about to be evicted from your nursing home residence?
Is your legal question related to needed repairs on your rented property?
Other (please describe below)
Government Benefits Legal Issues
SNAP
Medicare
Medicaid
Seeking to become eligible for Medicaid to stay in a nursing home
SSI
Other (please describe below)
Life Planning Legal Issues
Will
Living Will/Health Care Surrogate
Other Legal Issue - if your Legal Issue Category is not listed, or you have selected "Other (please describe below)" - please describe your legal issue below:
Based on the current information provided we are not able to determine your eligibility. Please call our number at 859-431-8200 to find out if we can help you.
If I marked “yes” to the question about citizenship, I affirm with my signature collected on the next screen that I am in fact a citizen of the United States. If I marked no to the question, this affirmation does not apply.
Contact Information