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. LouisSt. Louis CountySt. Charles CountySt. Clair CountyOther

If "other" please specify:

Neighborhood:
College HillHyde ParkOld NorthPatchCarondeletOther

If "other" please specify:

Primary Phone Number: (required)

CellHomeWork

Secondary Phone:

CellHomeWork

Your Email: (required)

What is the best way to contact you?
Home PhoneCell PhoneEmail

Can we text you?
YesNo

Emergency Contact Name: (required)

Emergency Contact Phone: (required)

Gender:
MaleFemaleTransgenderOther

If "other" please specify:

Race/Ethnicity: (required)
African-AmericanCaucasian/WhiteHispanicBi-RacialMulti-RacialAsianNative AmericaHawaiian or Pacific IslanderOther

If "other" please specify:

Marital Status:
SingleMarriedOther

If "other" please specify:

Annual Household Income: (required) $

Number of Household Members: (required)

Type of Legal Issue: (required)
Housing / LandlordCollectionsEmploymentFamily LawLitigation / Contract DisputeLitigation / InjuryLitigation / OtherCriminalTaxSocial Sec. / MedicaidWillMunicipal OrdinanceTrafficVeteran AffairsOther

Summary of Problem: (required)

Have you been served with a lawsuit? (required)
YesNo

Have you appeared in court? (required)
YesNo

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.