Legal Intake

PRIVATE AND CONFIDENTIAL  

Name*

First Middle Last

Please provide your full legal name shown on your identification

Date of Appointment*

Gender*

M
F
Prefer not to say

Other names you are known by (if applicable):

Date of birth*

DD

MM

YYYY

Residential address*

Address Suburb Postcode

Postal address (if different from residential address)

Address Suburb Postcode

Phone number to be contacted on*

Email*

Is it safe to contact you on these details?*

Yes
No

Family Type

Not living in a family (e.g. boarder, alone, living in a hostel)
Sole Parent with dependent children
Two Parent Family with dependent children

Do you identify as

Aboriginal
Torres Strait Islander
Neither

Country of Birth

Year of Arrival

Main language spoken at home*

English

Proficiency in English*

Very Well
Well
Not Well

Proficiency in Written English*

Very Well
Well
Not Well

Do you require an interpreter? *

Yes ( If so what language )
No

Language*

Employment Status

Employed
Unemployed
Retired
Other

Centrelink Payments

No
Yes

If yes, what type?

Income Scale ($ per week)

Where did you find out about Brisbane North Community Legal Service: 

Are you experiencing financial hardship?

Yes
No
unsure

Have you experienced family/domestic violence

Yes
No
At risk of
Unknown

Are you at risk of homelessness?

Yes
No

Relationship Status

No. of dependent children

Do you have a disability?

No
Yes

If yes please state

Have you attempted to get assistance from Legal Aid Queensland about this matter?

If yes, specify

What is the name of all other party/parties involved in the matter?

1. Name*

First Last

D.O.B

Relationship to client*

2. Name

First Last

D.O.B

Relationship to client

Further information you would like the Solicitor to know about your legal issue.

Please upload documents related to legal matter. Please be aware the solicitor will not be reviewing the documentation you have provided until the time of the appointment

Drop files here or

I acknowledge that the advice/assistance provided to me is free of charge; the level of such advice/assistance is in the sole discretion of the lawyer providing it; a maximum of three appointments are given for the same legal matter; that there is no legal retainer between me and the Northside Connect Inc [operating the Brisbane North Community Legal Service and its Domestic Violence and Family Law Clinic] and that it does not represent me as lawyers and that any professional relationship is terminated upon the conclusion of the consultation. I FURTHER AUTHORISE YOU TO 1. Immediately scan into electronic form any file/documents pertaining to matters the subject of this advice and/or assistance and in your discretion destroy any and all hard copies AND 2. To destroy any files/documents in electronic form after no less than seven (7) years from today.

*

I confirm I have read and agree to Northside Connect's Privacy Notice