Minnesota RD Express

Minnesota Legal Risk Detector

The Minnesota Legal Risk Detector is a tool designed to help community partners spot when a client may benefit from legal help in particular areas. If the tool detects a potential legal issue, the Risk Detector provides you with resources you can give the person being screened. For issues within the case acceptance priorities of a regional legal aid program, the Risk Detector lets you submit a referral to that program so the person being screened can apply for free legal help. A collaboration of PBN, Southern Minnesota Regional Legal Services, Legal Services State Support

Disclaimer

The Legal Risk Detector is for informational purposes and is not legal advice. After filling out the Legal Risk Detector, your client may be asked if the client wants a non-profit law firm to contact them to offer legal help. Southern Minnesota Regional Legal Services, Inc. (SMRLS) will follow up with qualifying clients to do additional screening to see if SMRLS can provide legal help. By filling out the Legal Risk Detector, you as a service provider are agreeing that You received your client's consent to complete the Legal Risk Detector; You explained to your client Any reporting duties you may have unrelated to SMRLS and the Legal Risk Detector SMRLS provides free, confidential legal help. Your client may contact SMRLS directly if your client chooses not to complete the Legal Risk Detector. The client agreed to the Information Collection Policy.

Welcome

Please provide your information below.

First Name

Email:

Group, Organization, or Employer:

Client Profile

Please provide the client's contact information

First Name

Date of Birth: (YYYY-MM-DD)

What is your preferred language?*

English

Spanish

American Sign Language

Amharic

Arabic

Burmese

Cambodian

Hmong

Oromo

Somali

Tigrinya

Vietnamese

Other

Do you have a phone number you can be reached at?

Yes

Phone

I have issues with phone reception or I have hearing challenges. Please try calling several times.

When is the best time to call?

Morning

Afternoon

Either

Is it ok to leave voicemail on phone?*

Yes

Email:
Make sure this is a safe email address that you feel comfortable receiving emails at.

Home County:

Home Address Line 1:

Home Address Line 2:

Home City:

Home State:

Home Zip:

Is your mailing address different?

Yes

What's your mailing address?

Do you rent or own your home?
Please answer carefully - this determines key follow-up questions.

Rents (with or without public subsidy)

Owns

Neither

Additional Information

For residents of long-term care facilities, select "Rent"

Which best describes where you live now?

House

Apartment Building

Mobile Home

Assisted Living Facility or Nursing Home

Other

1 of 4: Housing

Regarding your housing, are any of these statements true?

My most recent landlord locked me out without first going to court within the past 30 days

My most recent landlord evicted me less than 30 days ago, and I could not attend the hearing

A hospital, nursing home, or assisted living made me leave when I still needed care

A shelter is denying me a bed when they have space

Please provide any notes to add to your answer above:

2 of 4: Benefits

Please select any benefits concerns that are true.

My Social Security income has been denied, reduced, or stopped

My SNAP benefits have been denied, reduced, or stopped

My Medical Assistance has been denied, reduced, or stopped

There has been a change to monthly Medical Assistance Spenddown or Waiver Obligation

I'm not getting services I have been approved for

My in-home services hours have been reduced or stopped, but I still need them

My insurance company or county worker has denied payment for medical care I need

Please provide any notes to add to your answer above:

3 of 4: Financial Safety

Please select any financial concerns that are true.

My credit report has negative things I don't understand

Someone else manages my money, and I think they aren't doing it right

Someone has asked me to sign something that I do not want to sign

I signed papers recently, but I don't know what I signed

I have given cash or property away

Someone else is using my ATM card, checkbook, or online banking

I don't have full access to my money or bank statements

I'm worried that my bills aren't being paid

I'm concerned about someone else having access to my bank account

I'm concerned about my joint bank account

I have questions about a Power of Attorney

I've been asked to send someone gift cards or transfer money

Someone keeps asking me for money even though I've said no

Please provide any notes to add to your answer above:

4 of 4: Personal Safety & Wellness

Please select any safety concerns that are true.

I would like to speak privately with an attorney about my safety

Someone is living in my home and refuses to leave

I am living with someone and I want to leave

Someone hurts or threatens my pet

Someone touches me without my consent

Someone makes me do things I do not want to do

Someone is taking things from me without asking

Someone is supposed to provide me care but is not doing it like they should

I can't fully care for myself

Please provide any notes to add to your answer above:

Upload Files

Would you like to upload documents, pictures, or videos to add to the information you provided above?

Yes

You can upload up to 3 files here. Most file formats accepted. Please keep videos to 30 seconds long at most.

File Upload

Choose File

File Upload

Choose File

File Upload

Choose File

Review

Any concerns you have identified are listed below for your review and verification. To change any inputs, click "Previous" Otherwise, click "I am satisfied..." to continue.

Caution:

You have not identified any risk flags. Please be sure this is correct. If needed, click "< Back" and change your answers.

Housing Risk Flags: 0

Benefits Risk Flags: 0

Financial Safety Risk Flags: 0

Personal Safety & Wellness Risk Flags: 0

Total Risk Flags Identified:

Consent

Please read the following to the client.

If you want, I can send this report with your answers to Southern Minnesota Regional Legal Services, Inc. (SMRLS). They will review the report and contact you directly to see whether you are eligible for their free legal help. Until they confirm you are eligible and your case is accepted, they are not your lawyers.

Do we have your permission to send your report, which includes your information and answers, to SMRLS?

Yes

Please note that if you do not submit the results of your interview to SMRLS, they will not follow up with you about any of the things we identified in this interview.