First Name: (required)

Middle Initial: (required)

Last Name: (required)

Date of Birth (mm/dd/yyyy): (required)

Address (include apartment #): (required)

City: (required)

State: (required)

Zip: (required)

County: (required)
 City of St. Louis St. Louis County St. Charles County St. Clair County Other

If "other" please specify:

Neighborhood:
 College Hill Hyde Park Old North Patch Carondelet Other

If "other" please specify:

Primary Phone Number: (required)

 Cell Home Work

Secondary Phone:

 Cell Home Work

Your Email: (required)

What is the best way to contact you?
 Home Phone Cell Phone Email

Can we text you?
 Yes No

Emergency Contact Name: (required)

Emergency Contact Phone: (required)

Gender:
 Male Female Transgender Other

If "other" please specify:

Race/Ethnicity: (required)
 African-American Caucasian/White Hispanic Bi-Racial Multi-Racial Asian Native America Hawaiian or Pacific Islander Other

If "other" please specify:

Marital Status:
 Single Married Other

If "other" please specify:

Annual Household Income: (required) $

Number of Household Members: (required)

Type of Legal Issue: (required)
 Housing / Landlord Collections Employment Family Law Litigation / Contract Dispute Litigation / Injury Litigation / Other Criminal Tax Social Sec. / Medicaid Will Municipal Ordinance Traffic Veteran Affairs Other

Summary of Problem: (required)

Have you been served with a lawsuit? (required)
 Yes No

Have you appeared in court? (required)
 Yes No

Name of opposing party: (required)

Contact information:

Grace Hill Health Centers is now Affinia Healthcare.

You can find them at www.affiniahealthcare.org or by calling 314.814.8700.