L&E Intake
Clinic Legal Services
[ { "type": "text", "required": true, "label": "Name", "placeholder": "Your First and Last Name", "className": "form-control", "name": "client_name", "subtype": "text" }, { "type": "text", "subtype": "email", "required": true, "label": "Email Address", "placeholder": "Your Email Address", "className": "form-control", "name": "client_email" }, { "type": "text", "subtype": "tel", "required": true, "label": "Phone Number", "placeholder": "xxx-xxx-xxxx", "className": "form-control", "name": "client_phone" }, { "type": "text", "required": true, "label": "Street Address", "className": "form-control", "name": "client_addr1", "subtype": "text" }, { "type": "text", "label": "Apartment, Suite, Unit, etc.", "className": "form-control", "name": "client_addr2", "subtype": "text" }, { "type": "text", "required": true, "label": "City", "className": "form-control", "name": "client_city", "subtype": "text" }, { "type": "select", "required": true, "label": "State", "className": "form-control", "name": "client_state", "values": [ { "label": "Alabama", "value": "AL" }, { "label": "Alaska", "value": "AK" }, { "label": "Arizona", "value": "AZ" }, { "label": "Arkansas", "value": "AR" }, { "label": "California", "value": "CA" }, { "label": "Colorado", "value": "CO" }, { "label": "Connecticut", "value": "CT" }, { "label": "Delaware", "value": "DE" }, { "label": "Florida", "value": "FL" }, { "label": "Georgia", "value": "GA" }, { "label": "Hawaii", "value": "HI" }, { "label": "Idaho", "value": "ID" }, { "label": "Illinois", "value": "IL" }, { "label": "Indiana", "value": "IN" }, { "label": "Iowa", "value": "IA" }, { "label": "Kansas", "value": "KS" }, { "label": "Kentucky", "value": "KY" }, { "label": "Louisiana", "value": "LA" }, { "label": "Maine", "value": "ME" }, { "label": "Maryland", "value": "MD" }, { "label": "Massachusetts", "value": "MA" }, { "label": "Michigan", "value": "MI" }, { "label": "Minnesota", "value": "MN" }, { "label": "Mississippi", "value": "MS" }, { "label": "Missouri", "value": "MO" }, { "label": "Montana", "value": "MT" }, { "label": "Nebraska", "value": "NE" }, { "label": "Nevada", "value": "NV" }, { "label": "New Hampshire", "value": "NH" }, { "label": "New Jersey", "value": "NJ" }, { "label": "New Mexico", "value": "NM" }, { "label": "New York", "value": "NY" }, { "label": "North Carolina", "value": "NC" }, { "label": "North Dakota", "value": "ND" }, { "label": "Ohio", "value": "OH" }, { "label": "Oklahoma", "value": "OK" }, { "label": "Oregon", "value": "OR" }, { "label": "Pennsylvania", "value": "PA" }, { "label": "Rhode Island", "value": "RI" }, { "label": "South Carolina", "value": "SC" }, { "label": "South Dakota", "value": "SD" }, { "label": "Tennessee", "value": "TN" }, { "label": "Texas", "value": "TX" }, { "label": "Utah", "value": "UT" }, { "label": "Vermont", "value": "VT" }, { "label": "Virginia", "value": "VA" }, { "label": "Washinton", "value": "WA" }, { "label": "West Virginia", "value": "WV" }, { "label": "Wisconsin", "value": "WI", "selected": true }, { "label": "Wyoming", "value": "WY" }, { "label": "Other", "value": "OTHER" } ] }, { "type": "number", "required": true, "label": "Zip Code", "placeholder": "5-digit zip code", "className": "form-control", "name": "client_zip", "min": "1", "max": "99999", "step": "0" }, { "type": "checkbox-group", "required": true, "label": "UW Affiliation (check all that apply)", "name": "client_uw_affiliation", "values": [ { "label": "UW-Madison Alumni", "value": "UWMSN-ALUM" }, { "label": "Other UW Alum", "value": "UW-ALUM" }, { "label": "Faculty", "value": "FACULTY" }, { "label": "Staff with a Faculty Appointment", "value": "FACSTAFF" }, { "label": "Research Assistant", "value": "RA" }, { "label": "Graduate Assistant", "value": "GA" }, { "label": "Post-Doc", "value": "POST" }, { "label": "Current Student, Graduate", "value": "GRADST" }, { "label": "Current Student, Undergraduate", "value": "UGRADST" }, { "label": "University Staff", "value": "USTAFF" }, { "label": "Other Staff", "value": "OSTAFF" }, { "label": "None", "value": "NONE" } ] }, { "type": "select", "required": true, "label": "Race", "className": "form-control", "name": "client_race", "values": [ { "label": "Decline to Answer", "value": "Decline", "selected": true }, { "label": "Asian", "value": "Asian" }, { "label": "Black", "value": "Black" }, { "label": "Hawaiian or Pacific", "value": "Pacific" }, { "label": "Latino or Hispanic", "value": "Hispanic" }, { "label": "Native American", "value": "Native" }, { "label": "White", "value": "White" } ] }, { "type": "select", "required": true, "label": "Disability", "className": "form-control", "name": "client_disability", "values": [ { "label": "Decline to Answer", "value": "Decline", "selected": true }, { "label": "Yes", "value": "Yes" }, { "label": "No", "value": "No" } ] }, { "type": "select", "required": true, "label": "Veteran", "className": "form-control", "name": "client_veteran", "values": [ { "label": "Decline to Answer", "value": "Decline", "selected": true }, { "label": "Yes", "value": "Yes" }, { "label": "No", "value": "No" } ] }, { "type": "select", "required": true, "label": "Gender", "className": "form-control", "name": "client_gender", "values": [ { "label": "Decline to Answer", "value": "Decline", "selected": true }, { "label": "Female", "value": "Female" }, { "label": "Male", "value": "Male" }, { "label": "Other", "value": "Other" } ] }, { "type": "header", "subtype": "h1", "label": "Business Information" }, { "type": "number", "required": true, "label": "Your Ownership Percentage", "className": "form-control", "name": "client_ownership_pct", "min": "0", "max": "100" }, { "type": "text", "required": true, "label": "Business Name", "placeholder": "If you don't have one yet enter \"TBD\"", "className": "form-control", "name": "client_business_name", "subtype": "text" }, { "type": "text", "label": "Company Website", "placeholder": "www.yoururlhere.com", "className": "form-control", "name": "client_website", "subtype": "text" }, { "type": "radio-group", "required": true, "label": "Industry", "name": "client_industry", "values": [ { "label": "Agriculture", "value": "Agriculture" }, { "label": "Business or Consumer Services", "value": "Services" }, { "label": "Education", "value": "Education" }, { "label": "Food and Beverage", "value": "FoodBev" }, { "label": "Health Care Services", "value": "Health Services" }, { "label": "Information Technology", "value": "IT" }, { "label": "Life Sciences and Biotech", "value": "Biotech" }, { "label": "Manufacturing", "value": "Manufacturing" }, { "label": "Medical Equipment", "value": "Medical Equipment" }, { "label": "Non-Profit", "value": "Non-Profit" }, { "label": "Real Estate", "value": "Real Estate" }, { "label": "Restaurant or Food Cart", "value": "Restaurant" }, { "label": "Retail", "value": "Retail" } ] }, { "type": "select", "required": true, "label": "Entity", "className": "form-control", "name": "client_entity", "values": [ { "label": "None", "value": "None", "selected": true }, { "label": "Benefit Corporation", "value": "BCORP" }, { "label": "C-Corporation", "value": "CCORP" }, { "label": "LLC", "value": "LLC" }, { "label": "LLP", "value": "LLP" }, { "label": "Non-Profit", "value": "NONPROFIT" }, { "label": "Partnership", "value": "PSHIP" }, { "label": "S-Corp", "value": "SCORP" }, { "label": "Sole Proprietor", "value": "SOLE" }, { "label": "Other", "value": "OTHER" } ] }, { "type": "textarea", "required": true, "label": "Business Description", "placeholder": "In 3 or 4 sentences please describe your business and what it does.", "className": "form-control", "name": "client_business_concept", "subtype": "textarea", "rows": "5" }, { "type": "radio-group", "required": true, "label": "Was this part of a class at UW-Madison?", "inline": true, "name": "client_msn_class", "values": [ { "label": "Yes", "value": "Yes" }, { "label": "No", "value": "No" } ] }, { "type": "radio-group", "required": true, "label": "Do you have a prototype?", "inline": true, "name": "client_prototype", "values": [ { "label": "Yes", "value": "Yes" }, { "label": "No", "value": "No" }, { "label": "Not Applicable", "value": "NA" } ] }, { "type": "radio-group", "required": true, "label": "How long has this company been in operation?", "name": "client_years", "values": [ { "label": "0 years", "value": "0" }, { "label": "0-1 years", "value": "1" }, { "label": "1-3 years", "value": "3" }, { "label": "3-5 years", "value": "5" }, { "label": "5 or more years", "value": "6" } ] }, { "type": "radio-group", "required": true, "label": "What was this company's revenue for its most recent tax year?", "name": "client_revenue", "values": [ { "label": "$0 - $1000", "value": "0" }, { "label": "$1,001 - $5,000", "value": "1001" }, { "label": "$5,001 - $10,000", "value": "5001" }, { "label": "$10,001 - $25,000", "value": "10001" }, { "label": "$25,001 - $75,000", "value": "25001" }, { "label": "$75,001 - $200,000", "value": "75001" }, { "label": "$200,001 or more", "value": "200001" } ] }, { "type": "radio-group", "required": true, "label": "How did you find out about the L&E Clinic?", "name": "client_referral", "other": true, "values": [ { "label": "Accountant", "value": "Accountant" }, { "label": "Attorney", "value": "Attorney" }, { "label": "Current or Former Student", "value": "LECStudent" }, { "label": "Current or Former Supervisor", "value": "LECSupervisor" }, { "label": "Current or Former Client", "value": "LECClient" }, { "label": "Other UW Source", "value": "UW" }, { "label": "Local Small Business Development Center (SBDC)", "value": "SBDC" }, { "label": "Web Search", "value": "Search" }, { "label": "Law School", "value": "Law School" } ] } ]