Step 1
1. Your full name*
2. What is your date of birth?*
3. What is your address?*
4. What is your phone number?*
5. What is your email?
6. What are your preferred pronouns? He/HimShe/HerThey/Them
7. Do you identify as Aboriginal or Torres Strait Islander? Yes, AboriginalYes, Torres Strait IslanderYes, Aboriginal and Torres Strait IslanderNo
8. What is your relationship status? SingleDatingDe FactoMarriedSeparatedDivorcedWidowed
9. Do you have any children under 18 in your care? Yes, Full CustodyYes, Part CustodyNo
10. Were you born in Australia? YesNo
Where were you born? Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo The Democratic Republic Of TheCook IslandsCosta RicaCote D'Ivoire (Ivory Coast)Croatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey and AlderneyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong S.A.R.HungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau S.A.R.MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMan (Isle of)Marshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands AntillesNetherlands TheNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory OccupiedPanamaPapua new GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent And The GrenadinesSaint-BarthelemySaint-Martin (French part)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe
11. Do you need an interpreter? YesNo
For which language do you need an interpreter?* Select a languageEnglishAfarAbkhazianAfrikaansAmharicArabicAssameseAymaraAzerbaijaniBashkirByelorussianBulgarianBihariBislamaBengali/BanglaTibetanBretonCatalanCorsicanCzechWelshDanishGermanBhutaniGreekEsperantoSpanishEstonianBasquePersianFinnishFijiFaeroeseFrenchFrisianIrishScots/GaelicGalicianGuaraniGujaratiHausaHindiCroatianHungarianArmenianInterlinguaInterlingueInupiakIndonesianIcelandicItalianHebrewJapaneseYiddishJavaneseGeorgianKazakhGreenlandicCambodianKannadaKoreanKashmiriKurdishKirghizLatinLingalaLaothianLithuanianLatvian/LettishMalagasyMaoriMacedonianMalayalamMongolianMoldavianMarathiMalayMalteseBurmeseNauruNepaliDutchNorwegianOccitan(Afan)/Oromoor/OriyaPunjabiPolishPashto/PushtoPortugueseQuechuaRhaeto-RomanceKirundiRomanianRussianKinyarwandaSanskritSindhiSangroSerbo-CroatianSinghaleseSlovakSlovenianSamoanShonaSomaliAlbanianSerbianSiswatiSesothoSundaneseSwedishSwahiliTamilTeguluTajikThaiTigrinyaTurkmenTagalogSetswanaTongaTurkishTsongaTatarTwiUkrainianUrduUzbekVietnameseVolapukWolofXhosaYorubaChineseZulu
12. How well do you read and write? Very wellWellNot wellNot at all
13. Do you receive any Centrelink payments? YesNo
14. What is your approximate income per week (before tax)? $0 - $199$200 - $299$300 - $399$400 - $599$600 - $799$800 - $999$1,000 - $1,249$1,500 - $2,000$2,000+
15. Do you have a disability? YesNo
What is your disability?*
16. Do you have any special needs or requests you would like us to know about?*
1. What is your legal problem?*
2. What is the full name of the person or organisation your legal problem is with?*
1. Are you currently experiencing family violence? YesNo
2. Is it safe to leave a voicemail or a text message on your phone? YesNo
How can we contact you to ensure your safety?*
Back
1. Your name*
2. Name of organisation*
3. Email address
4. Phone number*
5. Do you have consent to refer? We can only accept the referral if you have consent. Yes
Step 2
1. Client full name*
2. What is your client's date of birth?* Not sure
3. What is your client's address?* Not sure
4. What is your client's phone number?* Not sure
5. What is your client's email address? Not sure
6. What are your client's preferred pronouns? He/HimShe/HerThey/Them
7. Does your client identify as Aboriginal or Torres Strait Islander? Yes, AboriginalYes, Torres Strait IslanderYes, Aboriginal and Torres Strait IslanderNoNot sure
8. What is your client's relationship status? SingleDatingDe FactoMarriedSeparatedDivorcedWidowedNot sure
9. Does your client have any children under 18 in their care? Yes, Full CustodyYes, Part CustodyNoNot sure
10. Was your client born in Australia? YesNoNot sure
Where was your client born?* Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo The Democratic Republic Of TheCook IslandsCosta RicaCote D'Ivoire (Ivory Coast)Croatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey and AlderneyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong S.A.R.HungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau S.A.R.MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMan (Isle of)Marshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands AntillesNetherlands TheNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory OccupiedPanamaPapua new GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent And The GrenadinesSaint-BarthelemySaint-Martin (French part)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe
11. Does your client need an interpreter? YesNo
For which language does your client need an interpreter?* Select a languageEnglishAfarAbkhazianAfrikaansAmharicArabicAssameseAymaraAzerbaijaniBashkirByelorussianBulgarianBihariBislamaBengali/BanglaTibetanBretonCatalanCorsicanCzechWelshDanishGermanBhutaniGreekEsperantoSpanishEstonianBasquePersianFinnishFijiFaeroeseFrenchFrisianIrishScots/GaelicGalicianGuaraniGujaratiHausaHindiCroatianHungarianArmenianInterlinguaInterlingueInupiakIndonesianIcelandicItalianHebrewJapaneseYiddishJavaneseGeorgianKazakhGreenlandicCambodianKannadaKoreanKashmiriKurdishKirghizLatinLingalaLaothianLithuanianLatvian/LettishMalagasyMaoriMacedonianMalayalamMongolianMoldavianMarathiMalayMalteseBurmeseNauruNepaliDutchNorwegianOccitan(Afan)/Oromoor/OriyaPunjabiPolishPashto/PushtoPortugueseQuechuaRhaeto-RomanceKirundiRomanianRussianKinyarwandaSanskritSindhiSangroSerbo-CroatianSinghaleseSlovakSlovenianSamoanShonaSomaliAlbanianSerbianSiswatiSesothoSundaneseSwedishSwahiliTamilTeguluTajikThaiTigrinyaTurkmenTagalogSetswanaTongaTurkishTsongaTatarTwiUkrainianUrduUzbekVietnameseVolapukWolofXhosaYorubaChineseZulu
12. How well does your client read and write? Very wellWellNot wellNot at allNot sure
13. Does your client receive any Centrelink payments? YesNoNot sure
14. What is your client's approximate income per week (before tax)? $0 - $199$200 - $299$300 - $399$400 - $599$600 - $799$800 - $999$1,000 - $1,249$1,500 - $2,000$2,000+Not sure
15. Does your client have a disability? YesNo
What is your clients disability?*
16. Does your client have any special needs or requests you would like us to know about?*
Step 3
1. What is your client's legal problem?*
2. What is the full name of the person or organisation your client's legal problem is with?*
Step 4
1. Is your client currently experiencing family violence? YesNo
2. Is it safe to leave a voicemail or a text message on your client's phone? YesNo
How can we contact your client to ensure their safety?*
