Training/Supervision Forms: General Client Representation ... · B ice breaking conversation is comfortable and sincere, not awkward, not too long, not Introduction B interviewer

OFFICE FORMS Training/Supervision Forms: Rules Governing Practical Training of Law Students .........................................................2 Weekly Supervision Forms ..................................................................................................7 Interviewing Rubric .............................................................................................................9 Client Release for Taping/Monitoring ...............................................................................11 General Client Representation Forms: Clinic Letterhead ................................................................................................................12 Fax Coversheet...................................................................................................................13 Social Security/SSI Disability Screening...........................................................................14 Intake Sheet ........................................................................................................................15 Introduction Letter .............................................................................................................17 Client Representation Contract ..........................................................................................18 Appointment Confirmation Letter & Directions................................................................20 Medical Release Form (Consent to Release Confidential Information) ............................23 Release to Third Parties .....................................................................................................24 General Release Form ........................................................................................................25 Opening Memo ..................................................................................................................26 Student Authorization court form ......................................................................................27 Closing Letter.....................................................................................................................28 Client Feedback Form ........................................................................................................29 Closing Memo ....................................................................................................................32 Transfer Letter ...................................................................................................................34 Transfer Memo...................................................................................................................35

North Carolina Bar

Rules Governing Practical Training of Law Students

.0201 Purpose

The following rules are adopted to encourage law schools to provide their students with supervised practical training of varying kinds during the period of their formal legal education and to enable law students to obtain supervised practical training while serving as legal interns for government agencies

.0202 Definitions

The following definitions shall apply to the terms used in this section: (1) Eligible persons - Persons who are unable financially to pay for the legal services of an attorney, as determined by a standard established by a judge of the General Court of Justice, a legal services corporation, or a law school legal aid clinic providing representation. "Eligible persons" includes non-profit organizations serving low-income communities.

(2) Government agencies - The federal or state government, any local government, or any agency, department, unit, or other entity of federal, state, or local government, specifically including a public defenders office or a district attorney's office.

(3) Law school - An ABA accredited law school or a law school actively seeking accreditation from the ABA and licensed by the Board of Governors of the University of North Carolina. If ABA accreditation is not obtained by a law school so licensed within three years of the commencement of classes, legal interns may not practice, pursuant to these rules, with any legal aid clinic of the law school.

(4) Legal aid clinic - A department, division, program, or course in a law school that operates under the supervision of an active member of the State Bar and renders legal services to eligible persons. (5) Legal intern - A law student who is certified to provide supervised representation to clients under the provisions of the rules of this Subchapter. (6) Legal services corporation - A nonprofit North Carolina corporation organized exclusively to provide representation to eligible persons. (7) Supervising attorney - An active member of the North Carolina State Bar who

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satisfies the requirements of Rule .0205 of this Subchapter and who supervises one or more legal interns.

Section .0200 Rules Governing Practical Training of Law Students

.0203 Eligibility

To engage in activities permitted by these rules, a law student must satisfy the following requirements: (1) be enrolled in a law school approved by the Council of the North Carolina State Bar; (2) have completed at least three semesters of the requirements for a professional degree in law (J.D. or its equivalent); (3) be certified in writing by a representative of his or her law school, authorized by the dean of the law school to provide such certification, as being of good character with requisite legal ability and training to perform as a legal intern; (4) be introduced to the court in which he or she is appearing by an attorney admitted to practice in that court; (5) neither ask for nor receive any compensation or remuneration of any kind from any client for whom he or she renders services, but this shall not prevent an attorney, legal services corporation, law school, or government agency from paying compensation to the law student or charging or collecting a fee for legal services performed by such law student;

(6) certify in writing that he or she has read and is familiar with the North Carolina Revised Rules of Professional Conduct and the opinions interpretive thereof.

.0204 Certification as Legal Intern

Upon receipt of the written materials required by Rule .0203(3) and (6) and Rule .0205(6), the North Carolina State Bar shall certify that the law student may serve as a legal intern. The certification shall be subject to the following limitations: (a) Duration. The certification shall be effective for 18 months or until the announcement of the results of the first bar examination following the legal intern's graduation whichever is earlier. If the legal intern passes the bar examination, the certification shall remain in effect until the legal intern is sworn-in by a court and admitted to the bar. (b) Withdrawal of Certification. The certification shall be withdrawn by the State Bar, without hearing or a showing of cause, upon receipt of

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(1) notice from a representative of the legal intern's law school, authorized to act by the dean of the law school, that the legal intern has not graduated but is no longer enrolled; (2) notice from a representative of the legal intern's law school, authorized to act by the dean of the law school, that the legal intern is no longer in good standing at the law school; (3) notice from a supervising attorney that the supervising attorney is no longer supervising the legal intern and that no other qualified attorney has assumed the supervision of the legal intern; or (4) notice from a judge before whom the legal intern has appeared that the certification should be withdrawn.

.0205 Supervision

(a) A supervising attorney shall (1) be an active member of the North Carolina State Bar who has practiced law as a full-time occupation for at least two years; (2) supervise no more than two legal interns concurrently, provided, however, there is no limit on the number of legal interns who may be supervised concurrently by an attorney who is a full-time member of a law school's faculty or staff whose primary responsibility is supervising legal interns in a legal aid clinic and, further provided, that an attorney who supervises legal interns through an externship or out-placement program of a law school legal aid clinic may supervise up to five legal interns; (3) assume personal professional responsibility for any work undertaken by a legal intern while under his or her supervision; (4) assist and counsel with a legal intern in the activities permitted by these rules and review such activities with the legal intern, all to the extent required for the proper practical training of the legal intern and the protection of the client; (5) read, approve and personally sign any pleadings or other papers prepared by a legal intern prior to the filing thereof, and read and approve any documents prepared by a legal intern for execution by a client or third party prior to the execution thereof; (6) prior to commencing the supervision, assume responsibility for supervising a legal intern by filing with the North Carolina State Bar a signed notice setting forth the period during which supervising attorney expects to supervise the activities of an identified legal intern, and that the supervising attorney will adequately supervise the legal intern in accordance with these rules; and

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(7) notify the North Carolina State Bar in writing promptly whenever the supervision of a legal intern ceases.

.0206 Activities

(a) A properly certified legal intern may engage in the activities provided in this rule under the supervision of an attorney qualified and acting in accordance with the provisions of Rule .0205 of this subchapter. (b) Without the presence of the supervising attorney, a legal intern may give advice to a client, including a government agency, on legal matters provided that the legal intern gives a clear prior explanation that the legal intern is not an attorney and the supervising attorney has given the legal intern permission to render legal advice in the subject area involved.

(c) A legal intern may represent an eligible person, the state in criminal prosecutions, a criminal defendant who is represented by the public defender, or a government agency in any proceeding before a federal, state, or local tribunal, including an administrative agency, if prior consent is obtained from the tribunal or agency upon application of the supervising attorney. Each appearance before the tribunal or agency shall be subject to any limitations imposed by the tribunal or agency including, but not limited to, the requirement that the supervising attorney physically accompany the legal intern.

(d) In all cases under this rule in which a legal intern makes an appearance before a tribunal or agency on behalf of a client who is an individual, the legal intern shall have the written consent in advance of the client. The client shall be given a clear explanation, prior to the giving of his or her consent, that the legal intern is not an attorney. This consent shall be filed with the tribunal and made a part of the record in the case. In all cases in which a legal intern makes an appearance before a tribunal or agency on behalf a government agency, the consent of the government agency shall be presumed if the legal intern is participating in an internship program of the government agency. A statement advising the court of the legal intern�s participation in an internship program of the government agency shall be filed with the tribunal and made a part of the record in the case. (e) In all cases under this rule in which a legal intern is permitted to make an appearance before a tribunal or agency, subject to any limitations imposed by the tribunal, the legal intern may engage in all activities appropriate to the representation of the client, including, without limitation, selection of and argument to the jury, examination and cross-examination of witnesses, motions and arguments thereon, and giving notice of appeal.

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.0207 Use of Student's Name

(a) A legal intern's name may properly (1) be printed or typed on briefs, pleadings, and other similar documents on which the legal intern has worked with or under the direction of the supervising attorney, provided the legal intern is clearly identified as a legal intern certified under these rules, and provided further that the legal intern shall not sign his or her name to such briefs, pleadings, or other similar documents; (2) be signed to letters written on the letterhead of the supervising attorney, legal aid clinic, or government agency, provided there appears below the legal intern's signature a clear identification that the legal intern is certified under these rules. An appropriate designation is "Certified Legal Intern under the Supervision of [supervising attorney]."

(b) A student's name may not appear

(1) on the letterhead of a supervising attorney, legal aid clinic, or government agency;

(2) on a business card bearing the name of a supervising attorney, legal aid clinic, or government agency; or

(3) on a business card identifying the legal intern as certified under these rules.

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SUPERVISION MEETING

Date:

Student Representative

Hours since last meeting

Total Hours

ALL Open Cases

1.

2.

3.

4.

5.

Agenda for Meeting

1.

2.

3.

4.

5.

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WEEKLY CASE REVIEW

Date

Student

Client & Matter

Supervising Attorney

Brief Summary of current case status:

Case semester plan:

Tasks from last meeting Status

1. .

2. .

3. .

4. .

Comments on above:

Proposed Task to be completed before next meeting

1. .

2. .

3. .

4. .

Other comments:

Tasks to be done at a future time - not the coming week

1. .

2. .

3. .

4. .

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Interviewer: ________________________Client: ___________________________Date:____________ Skill/characteristic

Rating: 0-not observed 1-inconsistent 2-done well; consistent

Examples/Observations

First interaction

Bis welcoming & friendly

B ice breaking conversation is comfortable and sincere, not awkward, not too long, not

Introduction

B interviewer identifies self as a law student under supervision

B interviewer explains purpose of interview and other information about the clinic & interview process (including that what the client says is confidential)

B interviewer invites client questions about process before proceeding

B interviewer elicits any time constraints of client

First substantive question

B open-ended question that allows client to communicate desired information

B begins the interview at an appropriate place

Initial counseling

B if appropriate, interviewer presents client with explanation of relevant legal framework

Follow up questions

B assist client in providing information needed for assessing case

B assist client in providing information in an organized way that allows interviewer to understand story well

B elicit missing details & clarify information

B review information received to assure

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Skill/characteristic

Rating: 0-not observed 1-inconsistent 2-done well; consistent

Examples/Observations

accuracy and completeness Ending the interview

B interviewer summarizes client=s goals

B interviewer provides (if he/she can do it accurately) information about the applicable law and procedures that affect case

B interviewer sets out clearly what will happen next

B interviewer clearly communicates what the client needs to do, if anything

B interviewer solicits questions from the client

B client is asked to sign necessary releases and releases are explained to him/her

General interactions

B interview reflects that interviewer is prepared for the interview, has appropriate documents, and has an understanding of what information should be elicited.

B interviewer makes good eye contact

B interviewer avoids interruptions of interviewee (or uses interruptions appropriately and not too often)

B interviewer engages in Aactive listening@ by communicating, either through words or expression, that the interviewer is hearing the client=s story

B interviewer uses an appropriate blend of open-ended and closed-ended questions, framing statements, and funnel sequence

B interviewer inspires trust and appears to have gained respect of client

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Duke Legal Clinics

Taping/Monitoring Agreement I,___________________________, give my permission for my

interview at the Duke Legal Clinics to be viewed remotely by a supervising

attorney and/or videotaped or audiotaped, for the purposes of internal review

and teaching by students and instructors participating in the Duke Legal

Clinics. I understand that any recording made of my interview will only be

used by the clinic students and instructors for internal educational purposes

with the Duke Legal Clinics, and will not be used for any other purpose

without my consent.

I understand that I may refuse to have my interview taped or viewed

remotely, and that my decision will have no bearing on whether my case will

be accepted by the Duke Legal Clinics.

____________________________ ______________________________ Printed Name Signature Date: ______________________________

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Duke Law School

Box 90360 Durham, NC 27708-0360

Allison Rice, Director Telephone: (919) 613-7169 Hannah Demeritt, Supervising Attorney Fax: (919) 613-7262

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Duke Law School Box 90360

Durham, NC 27708-0360


FAX To:

Fax:

From:

Date:

Re:

Transmitting _______ pages, including coversheet. If there are problems during

transmission, please call (919) 613-7169.

The information contained in this Facsimile is privileged and confidential information intended for the

sole use of the addressee. If the reader of this facsimile is not the intended recipient, you are hereby

notified that any dissemination, distribution or copying of this communication is strictly prohibited. If

you have received this FAX in error, please immediately notify the person listed above, and return the

original message to the sender at the address listed above.

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Social Security Disability/SSI Screening Screener’s name: Date

Prospect name: Referred by:

Date applied: Date last denied

Has prospect already appealed? yes no Date appealed

Reason for denial: disability other (specify)

Current stage in proceedings: pre‐application initial reconsideration ALJ appeal post ALJ Prior Application(s)? yes no If yes, date(s) denied at initial level

Appealed prior case? yes no What was level of final denial?

Does prospect already have an attorney? yes no Who? If the prospect already has an attorney, we will generally not be able to assist. Stop here.

Where does prospect get medical care?

Primary doctor Does doctor support? yes no unknown

Date of diagnosis: ______________ If HIV -- CD4: latest___ highest_____lowest_____

Date prospect became unable to work (i.e. became disabled)

Main impairments & symptoms: ☐ HIV ☐ Cancer ☐ Other Details: Prospect’s age Education:

Date last worked? Can prospect work now? yes no Why or why not?

Past work (15 years)(what kind of jobs?)

Health insurance? Private Medicaid VA ADAP uninsured Has prospect applied for Medicaid? yes no If denied, date of denial . Appealed? yes no Other pertinent information (substance use, hospitalizations, etc.): (use back of sheet if needed)

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DUKE HEALTH JUSTICE CLINIC INTAKE SHEET

Date of Contact: Screener

PROSPECT CONTACT INFORMATION

Prospect Name:

Address: Phone 1:

☐ cell ☐ home ☐ work

Phone 2:


County: Phone 3:


Email:

Does client look at email regularly? ☐ Yes ☐ No

CAN MESSAGE BE LEFT? ☐ Yes ☐No

SPECIAL INSTRUCTIONS RE MESSAGES:

Alternate Contact

Name/Relation:

Phone:

How did client learn of our program?

Referring person:

Phone

Who called? ☐ Prospect ☐ Referring Person

Adverse Party, if any

Non Adverse Spouse/Partner

CASE INFORMATION

Type of Case:

☐ Documents ☐ SBG ☐ Disability ☐ Discrimination ☐ Privacy/confidentiality ☐ Insurance

☐ Other (specify)

Brief Description of Problem

Case Manager/Social Worker

Name:

Agency:

Phone:

Doctor:

Hospital/Clinic:

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DETAILED INFORMATION (Collect this information if decision is made to investigate or open case)

THIS INFORMATION GOES IN THE CLIENT CONTACT RECORD IN CLIO

CLIENT DETAILS:

Social Security Number (Collect only for Social Security or Medicaid cases)

Date of Birth:

Marital Status: ☐ M ☐D ☐W ☐Never M

Sex: ☐ Male ☐ Female ☐ Transgender

Racial/Ethnic Heritage

☐ White ☐Asian/Pacific Islander

☐ African-American ☐ Native Amer/Aleutian/Eskimo

☐ Hispanic ☐ Unknown

Health Status:

☐ HIV+

☐ Cancer

☐ Neither

Health Insurance

☐ Private ☐ No insurance

☐ Medicaid ☐ Other

☐ Medicare ☐ Unknown/unreported

☐ Other public

Total Number in Household: # Adults: # Minor Children:

Social Security Cases only: Mother’s Name: Client’s Place of Birth:

Other notes:

NET MONTHLY HOUSEHOLD INCOME Please get income for all members of household

ASSETS

Employment (client) Number of Vehicles

Employment (others) Year of vehicles

Social Security (client) Cash on hand/checking

Social Security (others) Savings

Workfirst or SSI (client) CDs/Stocks

Workfirst or SSI (others) Annuities/Investments

Unemployment (client) Home (value)

Unemployment (others) Other real estate

Pension (client) Mobile Home

Pension (others) Other

Worker’s Comp (client)

Worker’s Comp (others)

Self-employment (client)

Self-employment (others)

Other income

Total Income Total Assets

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Duke Law School

Box 90360 Durham, NC 27708-0360


Date Client name/address Dear Mr./Ms. Client: I am writing to introduce myself. I am the student who will be working with you on your case this semester. I will be your main contact. I will be working under the supervision of attorney [supervising attorney], who will review all of my work. All of our services are free. I can be reached by phone at (919) 613-7169 or toll free at (888) 600-7274. The best times to reach me are: [enter your office hours]. You can leave me a message at any time and I will call you back. I have enclosed a Client Representation Contract and Release. This has more details about how we will work together. Please sign one copy and return it to me in the enclosed envelope. The other copy is for you to keep. I look forward to working with you. Sincerely, [student name] Certified Law Student Under the supervision of [supervising attorney name] Supervising Attorney

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DUKE HEALTH JUSTICE CLINIC

CLIENT REPRESENTATION CONTRACT

I, _____________________________, retain The Duke Health Justice Clinic, to represent me in

my case about ☐ Preparing legal documents ☐ Planning for Children/Standby Guardianship

☐ Disability ☐ Discrimination ☐ Privacy/confidentiality ☐ Insurance

☐ Other __________________________________________________

1. When this contract says "you" it means The Duke Health Justice Clinic. When it

says “I” it means me.

Who will be doing the work on my case:

2. Law Students: I understand work on my case will be done by law students and

law clerks under the supervision of a lawyer and that my case may be discussed with the other

law students and lawyers in the Duke Health Justice Clinic. I understand that if my case cannot

be finished during one law school semester, another law student will be assigned each

semester.

Fees and Money:

3. You will not charge me a fee for the work you do for me. If you have to pay

somebody else a fee for my case, I agree to pay you back. You will try to get those fees paid by

someone else when you can. Fees could be, for example, court fees, newspaper fees, court

reporter fees, doctor report fees. There may be other kinds of fees. You will inform me in

advance if money will be needed for any such fees or costs.

4. You may have a right to get lawyers fees from the other side in my case. If you

do, you will keep that money.

Confidentiality

5. Our relationship is based on mutual trust and honesty. I promise that the things

I have told you and will tell you are correct to the best of my ability. I promise to tell you if my

financial situation changes and to keep you up to date about what is happening in my case. You

promise to keep information you learn about me confidential, unless you get my permission to

tell others or there is some other special circumstance.

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How you will handle my case: 6. You may talk with people, write documents, start a lawsuit, negotiate and do other things to solve my problem. You may use the information I give you to do that. 7. If you represent me in problem with a government agency, a person or a business, you will investigate my case before you make any promise about taking any action on my behalf. If you do agree to represent me in a lawsuit or disability claim, you do not promise to appeal my case if we lose at first or if I am not satisfied with the result. 8. If you represent me in a case with government agency, a person or a business, you will not settle my case without my consent. 9. You might withdraw from my case if I am later found to be ineligible for your services. You will not withdraw from my case because of that unless the Rules of Professional Conduct permit it and it would not be unduly prejudicial to my case. 10. I will tell you whenever I move so you can find me. If I don't tell you when I move, you may withdraw from my case. 11. You may withdraw from my case if you don't have the funding to continue. 12. I have read or heard this contract, and I understand it. I have been given a copy of this contract. Date:___________________________ Duke Legal Assistance Project ________________________________ [Client Name] Client

____________________________________ [Your name] Student Representative

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Duke Law School

Box 90360 Durham, NC 27708-0360


Date Client name/address Dear Mr./Ms. Client: I am writing to confirm our meeting on [enter date of meeting] at [enter time of meeting]. I have enclosed a parking pass and directions to the Duke Law School Clinics. You can swipe the parking pass at the gated entry to our parking lot. If that parking pass doesn’t work, ring the buzzer at the gate and let the person know you are here for a meeting with the Duke Law Clinic. They should let you in. Once you get into the lot, there is a designated clinic parking spot close to the law school building at the end of a long sidewalk. The spot is marked with a small, blue sign. If that parking spot is taken, you may park anywhere, but make sure your parking pass is displayed by either hanging it from your rear view mirror or displaying it on your car’s dashboard. To get to our office from the parking lot, take the long sidewalk in front of the clinic parking spot. Follow that to the building. There is a glass door at the end of the sidewalk. The Clinic is on the second floor, one flight up. If you prefer, there is also an elevator. I look forward to meeting you on [enter meeting date]. Please let me know if you have any questions about visiting the Clinic or the [indicate any paperwork client should bring] that I have asked for. I can be reached at (919) 613-7169. I look forward to working with you. Sincerely, [Student name] Certified Law Student Under the Supervision of [supervising attorney name] Supervising Attorney Enclosures: Directions to the Duke Law Clinics Parking Pass

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DIRECTIONS TO DUKE LAW CLINICS The Duke Law School Clinics are located on the second floor of Duke Law School, corner of Science Drive and Towerview Road on the Duke University Campus. The street address is 210 Science Drive, Durham. This is not marked on the building. See below for directions from Duke Hospital, Raleigh, and I-85. The phone number at the Duke Law Clinics is 919-613-7169 or 1-888-600-7274. Entering the Law School parking lot and building: If you have a parking pass, slide it through the card reader. Otherwise, press the button and tell the receptionist that you are visiting the Duke Law Clinics. (The receptionist is on duty between 8:30 a.m. and 5:00 p.m. You may park anywhere in the lot, although there is a designated space near the building just past the stair opening. Follow the long sidewalk along the side of the building and enter. You may take the elevator or walk up the stairs to the second floor. The Duke Law Clinics are through the glass double doors.

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From Duke Hospital on Erwin Road: With the hospital on your left, continue west on Erwin Road to the traffic light at Morreene Road (on right) and Towerview Road (on left). Turn left onto Towerview. Pass the stop sign, then look for a gated lot on your right. (If you get to Science Drive, you have gone too far.) Turn into the lot and stop at the gate. See instructions above for entering the Law lot and building. From Raleigh via the Durham Freeway (147): Take I-40 to NC147. Follow NC147 to the exit for US15-501 South. Once on US 15-501 South, immediately take the exit for Morrene Road. Turn left onto Morrene Road. Follow Morrene across Erwin Road, where Morrene becomes Towerview Road. Pass the stop sign, then look for a gated lot on your right. (If you get to Science Drive, you have gone too far.) Turn into the lot and stop at the gate. See instructions above for entering the Law lot and building. From I-85 North - From Hillsborough, Greensboro, Charlotte: Take I-85 North to the exit 172 for the Durham Freeway, NC 147. Shortly after this exit, take the exit for 15-501 South. Once on US 15-501 South, immediately take the exit for Morreene Road. Turn left onto Morreene Road. Follow Morreene across Erwin Road, where it becomes Towerview Road. Pass the stop sign, then look for a gated lot on your right. (If you get to Science Drive, you have gone too far.) Turn into the lot and stop at the gate. See instructions above for entering the Law lot and building. From I-85 South -- Oxford, Henderson, Virginia: Take I-85 South to US15-501 South. Exit 15-501 at Morreene Road. Turn left onto Morreene Road. Follow Morreene across Erwin Road, where it becomes Towerview Road. Pass the stop sign, then look for a gated lot on your right. (If you get to Science Drive, you have gone too far.) Turn into the lot and stop at the gate. See instructions above for entering the Law lot and building

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CONSENT TO RELEASE CONFIDENTIAL MEDICAL INFORMATION

To: __________________________________________ Re: __________________________________________ Date of Birth: __________________________________________ Dates Requested: __________________________________________

I, ____________________________authorize you to disclose to the Health

Justice Clinic of Duke University School of Law, any and all past, present, and future

records, reports, or other information you have on file concerning my medical condition,

specifically including records relating to HIV/AIDS, psychiatric or psychological reports,

evaluations, and treatment records and any information relating to substance abuse,

including drug and/or alcohol treatment records. The purpose of the release of

information is legal representation.

I understand that, once disclosed, my medical information will no longer be

protected by the Health Information Privacy Protection Act (“HIPPA”) and may be subject

to redisclosure by Duke Health Justice Clinic. I also understand that Duke Duke Health

Justice Clinic will not redisclose my medical information except to the extent necessary

to provide legal representation.

I understand that I may refuse to sign this authorization and that my refusal to

sign will not affect my ability to obtain treatment or payment or my eligibility for benefits.

I may inspect or copy any information used/disclosed under this authorization to the

extent allowed by law.

I understand my consent is revocable, except to the extent that action has

already been taken; otherwise, this Consent remains in effect for one year from the date

it was signed.

You are authorized and requested to accept this authorization, whether it bears

an original or photostatic copy of my signature. ________________________ __________________________________________ Date

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CONSENT TO RELEASE CONFIDENTIAL INFORMATION

I, _________________________________________, authorize Duke Health

Justice Clinic to disclose to ____________________________________, any and all

past, present, and future records, reports, or other information you have relating to the

Clinic’s representation of me. This includes authority to discuss my case and share

confidential information with the person(s) named above.

I understand that I can revoke my consent, except to the extent that action has

already been taken; otherwise, this Consent remains in effect for one year from the date

it was signed.

You are authorized and requested to accept this authorization, whether it bears

an original or photostatic copy of my signature. __________________________ ___________________________________ Date Name

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CONSENT TO RELEASE CONFIDENTIAL INFORMATION TO: ______________________________________

I, __________________________________authorize you to disclose to

the Duke Health Justice Clinic, any and all past, present, and future records,

reports, or other information you have on file concerning:

__________________________________________________________

I understand my consent is revocable, except to the extent that action has

already been taken; otherwise, this Consent remains in effect for one year from

the date it was signed.

You are authorized and requested to accept this authorization, whether it

bears an original or photostatic copy of my signature.

________________________________ Printed name: ________________________________ Date

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OPENING MEMO Client Name: Date: Student Rep:

Supervising Attorney:

List all potential conflicts & relationship to client/case:Spouse or Partner Adverse Parties (in SBG, include all absent parents and others with interest in child) Other potential conflicts: Facts: [Use as much space as necessary] Student/Client Promises: Client’s Goals: Calendar Items: DEADLINES: (Statutes of limitations, appeal deadlines, or other deadlines (put in Clio also) ☐ No Deadlines Dates of hearings and/or follow-up appointments (please put into Clio also)

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STATE OF NORTH CAROLINA COUNTY OF IN THE MATTER OF: Child's Name

) ) ) ) ) ) ) ) ) )

IN THE GENERAL COURT OF JUSTICE SUPERIOR COURT DIVISION

BEFORE THE CLERK

FILE NO.

AUTHORIZATION OF STUDENT REPRESENTATION PURSUANT TO

N.C. STATE BAR RULES SUBCHAPTER C .0200

This is to acknowledge that I, [Client's Name], have been informed that [Student's Name] is a

law student who has completed at least three semesters and is in good standing at Duke

University School of Law appearing in civil proceedings in the Courts of the State in accordance

with the North Carolina State Bar Rules, Subchapter C, Rule .0200. I hereby authorize the

above-named student to represent me.

___________________________ [Client's Name] I, Allison J. Rice, am the supervising attorney of the above-named student, and hereby approve her representation of the above-named client. _________________________________ Date Allison J. Rice Duke University School of Law Legal Assistance Project Durham, N.C.

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Duke Law School

Box 90360 Durham, NC 27708-0360


Date Client Name/Address Dear Ms./Mr. Client: [insert personalized text – eg reference to resolving case, meeting and getting documents signed, etc.] Now that we have completed the work we agreed to do, we will be closing your file at the Duke Health Justice Clinic. As you know, we [state what we did for the client, e.g. "prepared a Will, Living Will and Power of Attorney." Also, add something personal, if possible. Also include any reminders about anything the client needs to do.] I am pleased that we were able to provide this service to you. We would like to hear from you about your experience working with us. Please fill out the enclosed survey and return it to us in the enclosed envelope. This will help us better meet the needs of our clients. If you need additional legal assistance, I hope that you will call upon us again. I wish you all the best. Sincerely, [Student Name] Certified Law Student Under the Supervision of [Supervising Attorney Name] Supervising Attorney Enclosures: Client Feedback Form Return Envelope

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Duke Health Justice Clinic

CLIENT FEEDBACK

Your Name:___________________________________________ Law Student(s) you worked with:__________________________________ Please answer these questions to let us know how you felt about your experience with the Duke Health Justice Clinic. Your honest answers will help improve the services Duke Health Justice Clinic is able to offer. We hope your law student can learn from your answer, but we will only share them with your student if you give us permission. 1. How did you first hear about the Duke Health Justice Clinic? � Case manager � Doctor, nurse, social worker at my clinic � Friend or family member � Flier or brochure � Other: ________________________________________________ 2. What kind of legal problem(s) did the Duke Health Justice Clinic help you with? � Documents (Power of Attorney, Health Care Power of Attorney, Living Will) � Will � Benefits (Social Security, Disability, Medicaid, Health Insurance) � Standby Guardianship � Discrimination � Breach of Confidentiality � Other: ________________________________________________ 3. Would you come back to the Duke Health Justice Clinic if you had another legal problem? � Yes �No �Don’t Know 4. Would you refer your friends or family members to Duke Health Justice Clinic if they had a legal problem? �Yes �No �Don’t Know

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5. As you know, a law student handled your case. Please answer the following questions by circling the number closest to your answer. A. How satisfied are you with the services of the Duke Health Justice Clinic?

Not satisfied Neutral Very satisfied 1 2 3 4 5 6 B. How was your first meeting with your student? Very Poor Neutral Excellent 1 2 3 4 5 6 C. How well did the student understand your legal problem and what you wanted to do about it? Very poorly Acceptable Very Well 1 2 3 4 5 6 D. How well did the student explain the law in your case to you? Very poorly Acceptable Very Well 1 2 3 4 5 6 E. How well did the student help you understand your legal options and decisions in your case? Very poorly Acceptable Very Well 1 2 3 4 5 6 F. How well did the student keep in touch with you about what was happening with your case? Very poorly Acceptable Very Well 1 2 3 4 5 6 G. How prepared was the student when s/he met with you or went to court with you? Poorly prepared Acceptable Very prepared 1 2 3 4 5 6 H. Was the student respectful and professional? Very unprofessional Neutral Very professional 1 2 3 4 5 6

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I. Overall, how well did your student represent you and help you with your legal problem? Very poorly Acceptable Very Well 1 2 3 4 5 6 May we share your answers with the student(s) who worked with you? Yes____ No____ Do you have any further comments or suggestions for the Duke Health Justice Clinic? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for your help!

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CLOSING MEMO Client’s Name: Date: Student Representative

Supervising Attorney

Total Hours Date Opened Briefly Describe the client’s legal issue(s) what work the clinic performed, and the results (Use as much space as you need): Issues addressed (check all that apply); ☐ Documents ☐ Private Insurance ☐ Permanency Planning ☐ Employment ☐ Government Benefits ☐ Confidentiality ☐ Discrimination ☐ Other (specify) Documents: Give the DATE of all documents executed Will HCPOA Living Will Power of Attorney HCPOA for Minor Power of Attorney for Minor Other (specify) Document Distribution: Give the DATE letters sent to register of deed, doctor, others Register of Deeds Doctor Agent(s) Other (specify) Permanency Planning SBG (give dates) Designation signed Consent Signed Petition Filed Hearing held Order Letters issued Other permanency planning: Check those handled, and give date of disposition ☐ Adoption ☐ Custody Government Benefits – Check those handled ☐ Medicaid ☐ SSI ☐ SSDI ☐ Other For Disability cases: Benefits Paid? ☐ Yes ☐ No

At what stage of case: ☐ Reconsideration ☐ On the Record ☐ After Hearing

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Private Insurance – check those handled: ☐ Health ☐ Short Term Disability ☐ Long Term Disability ☐ Life Other Matters ☐ Privacy/Confidentiality ☐ Discrimination ☐ Other (specify): Check Opening Memo and list all legal issues we agreed to handle (use as much space as you need): Has all the agreed work been done? ☐ Yes ☐ No If not, explain why Were all original documents returned to Client? ☐ Yes ☐ No Has the closing letter been sent? ☐ Yes ☐ No If not, explain File cleaning complete? ☐ Yes ☐ No (Remove drafts, previous copies of case notes, duplicates, etc) Final case notes printed out and inserted in file? ☐ Yes ☐ No Please reflect about your representation of this client . (Use as much space as you need)

� Briefly describe the skills you have developed in handling this case, � the impact your representation had on the client, � the aspects of your representation you think were particularly effective, � and anything you might have done differently.

When file closing is complete, please give the file to the Supervising Attorney. Supervising Attorney’s Closing Approval: Date and Initials:

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Duke Law School

Box 90360 Durham, NC 27708-0360


Date Client Name/Address Dear Mr./Ms. Client: I am writing to let you know that I will be finishing my work with the Duke Law Clinics on [date you will be finishing up clinic]. As soon as a new student is assigned to handle your case, that student will contact you. In the meantime, your case will be handled by supervising attorney, [name of supervising attorney]. She can be reached at (919) 613-7169. [Put case specific comments here, such as what will happen next, case update, what’s happened so far] I enjoyed working on your case. I hope that your experience with the Duke Law Clinics has been and continues to be positive. I wish you all the best. Sincerely, [student name] Certified Law Student Under the Supervision of [supervising attorney] Supervising Attorney

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TRANSFER MEMO To: From: Re: Date:

Type of Case: Summary of what has taken place so far: [summary of case] Description of what needs to be done to close case: [detail what is left to do] Client’s expectations and promises made to client (include time frame) Other remarks that may be helpful to new representative Transfer letter written?

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ADMN-Admin Documents and Forms 07/03/2015

Correspondence 07/09/2015










SSA Correspondence 07/28/2015







Form 07/25/2015

ENV-Envelope 07/09/2015





Releases 07/25/2015

Filename Category Last Modified Last Modified By

Health - Case Data Sheet.docx Allison Rice

Health Justice - Appointment Confirmation Letter &Directions.docx

Allison Rice

Health Justice - Closing Letter & Survey.docx Allison Rice

Health Justice - Closing Memo.docx Allison Rice

Health Justice - Cover letter to agent - DPOA only.docx Allison Rice

Health Justice - Cover letter to agent - HCPOA & DPOA.docx Allison Rice

Health Justice - Cover letter to agent - HCPOA only.docx Allison Rice

Health Justice - Cover letter to Doctor - HCPOA-LW.docx Allison Rice

Health Justice - Cover letter to hospital - HCPOA-LW.docx Allison Rice

Health Justice - disability - decline case.docx Allison Rice

Health Justice - disability - releases not returned.docx Allison Rice

Health Justice - disability - Request for SSA file.docx Allison Rice

Health Justice - disability - send releases.docx Allison Rice

Health Justice - disability followup - need to reapply.docx Allison Rice

Health Justice - disability followup - unable to reach byphone.docx

Allison Rice

Health Justice - Faxcoversheet.docx Allison Rice

Health Justice - Register of Deeds Cover Letter.docx Allison Rice

Health Justice Client Representation Contract.docx Allison Rice

Health Justice Disability Forms Packet.pdf Allison Rice

Health Justice Envelope.docx Allison Rice

Health Justice Intake Sheet.docx Allison Rice

Health Justice Introduction Letter to Client.docx Allison Rice

Health Justice Letter to Client.docx Allison Rice

Health Justice Letterhead.docx Allison Rice

Health Justice Medical Release.docx Allison Rice

Clio - Document Templates https://app.goclio.com/document_templates

1 of 1 8/18/2015 10:08 AM

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Releases 07/28/2015




Medical Record Request 07/25/2015




Filename Category Last Modified Last Modified By

Health Justice Non-medical release.docx Allison Rice

Health Justice Opening Memo - Disability.docx Allison Rice

Health Justice Opening Memo - Documents.docx Allison Rice

Health Justice Opening Memo.docx Allison Rice

Health Justice Request for Medical Records.docx Allison Rice

Health Justice Return Envelope.docx Allison Rice

Health Justice Transfer letter.docx Allison Rice

Health Justice Transfer Memo.docx Allison Rice

Clio - Document Templates https://app.goclio.com/document_templates

1 of 1 8/18/2015 10:09 AM

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