Providing timely, compassionate legal services.

Client Qualifying Survey

All clients of Legal Hospice of Texas must meet certain requirements to qualify for services. Answering the questions on this survey will help you to know if you can qualify. You must answer every question truthfully. If and when you register as a client, written documentation of your answers will be required.

Section 1 - Health Conditions/Diagnosis

Select choices

I am HIV+ or I have AIDS
A doctor has told me that I have a terminal illness
A doctor has told me that I have one of the following illnesses: Parkinson’s Disease, Alzheimer's Disease, Lou Gehrig's Disease (ALS), Muscular Dystrophy, or Multiple Sclerosis
A doctor has told me that I am at "end stage" of a chronic illness

If you did not check at least one of the boxes above, you do not qualify for our services

Section 2 - County of Residence

Select choices

I live in one of the following counties: Collin, Cooke, Dallas, Denton, Ellis, Fannin, Grayson, Henderson,Hood, Hunt, Johnson, Kaufman, Navarro, Parker, Rockwall, Tarrant

If you did not check box above, you do not qualify for our services.

Section 3 - Legal Issue

Select choices

The legal issue I have is directly related to the illness I checked above. (insurance issues, wills, powers of attorney, Social Security or other public benefit, housing, access to medical care, employment discrimination)

If you did not check box above, you do not qualify for our services.

Section 4 - Income

Income for ALL non-HIV+ clients and ALL clients from Hood, Johnson, Parker and Tarrant counties is capped at 125% of Federal Poverty Level. Currently that cap is $12,763 for a single person; $17,113 for a family of 2; $21,463 for a family of 3; $25,813 for a family of 4.

Select choices

I am not HIV+ or I live in Hood, Johnson, Parker or Tarrant County AND my income is not more than listed above.

Income for HIV+ clients living in Collin, Cooke, Dallas, Denton, Ellis, Fannin, Grayson, Henderson, Hunt, Kaufman, Navarro,and Rockwall counties is capped at 300% of Federal Poverty Level. Currently that cap is $30,630 for a single person; $41,070 for a family of 2; $51,510 for a family of 3; $61,950 for a family of 4.

Select choices

I am HIV+ and I live in Collin, Cooke, Dallas, Denton, Ellis, Fannin, Grayson, Henderson, Hunt, Kaufman, Navarro or Rockwall County AND my income is not more than that listed above.

If you did not check one of the boxes above, you do not qualify for our services.

214.521.6622 | info@legalhospice.org