Web Contact Form – Waterloo Region Community Legal Services

First and Last Name *

Date of Birth (DD/MM/YY) *

Phone Number *

Email Address *

Do you consent for us to contact you by e-mail? *

Street Address *

Unit Number (if applicable)

City *

Postal Code *

What is your primary source of income? *

What area of law do you need assistance with? *

If you selected Housing from the list above, please provide the name of your landlord.

Brief description of your issue *

Do you require any accommodations? (e.g. hearing impairment, language interpretation, e-mail only, etc.)