273 High St, Preston VIC 3072

Criminal Law Client Intake Form

Main menu

Please note – This form is to facilitate the capturing of intake and service provision infomation.

Client's First Name:

Client's Middle Name:

Client's Surname:

Other name(s):

Gender:

Date of Birth:

Date of birth is an estimate:

Mobile:

Other phone:

Email:

How can we contact you?

How did you know about VALS Criminal Law team?

If 'Previous client', please provide details:

If 'Referral from', please provide details:

If 'Community Referral (Family or Friend)', please provide details:

If 'Other', please provide details:

Are you experiencing, or at risk of, homelessness?

Residential Address (Line 1):

Residential Address (Line 2):

Suburb:

Postcode:

State:

Country:

Tick if your postal address is the same as the above:

Postal Address (if different from residential address):

Suburb:

Postcode:

State:

Country:

Authorised person (OPTIONAL):

Relationship (OPTIONAL):

Phone (OPTIONAL):

Do you require an interpreter?

If 'Yes', which language?

Rating of your writing skills?

Rating of your spoken English skills?

Do you have a disability or mental health issues?

If 'Yes', please select all disabilities that apply:

If you have a hearing disability, would you like us to contact you through the National Relay Service?

Are you Aboriginal and/or Torres Strait Islander?

Please select type of CoA provided:

Mum:

Dad:

Grandmother (Maternal):

Grandfather (Maternal):

Grandmother (Paternal):

Grandfather (Paternal):

Other:

Mob:

Internal COA confirmed by:

No conflict of interest:

Certificate of COA:

Statutory Declaration:

Internal COA:

Priority client characteristics (please select one or more):

Merit guideline met (determined by legal practitioner):

Means test does not apply:

Centrelink benefit or CDEP participant wages main source of income:

Gross household income below $52,000:

Cannot access finances temporarily:

Means test not met, but assistance not available from another service provider (assistance approved by Director of Legal Services):

Do you receive a Centrelink benefit or CDEP participant wages?

What is your Centrelink Customer Reference Number (CRN)?

What type of benefit do you receive?

If 'Other', please provide details:

Is this your main source of income?

What is your relationship status?

What is your gross household income (weekly/annual)?

Number of dependents (eg. children or elderly parents who live with you and who rely on your income)?

Is your gross household income under $52,000 (subtracting expenses and allowances)?

Do you have access to your finances at the moment?

Court date:

Court location:

Court:

If 'Other', please provide details:

Hearing type:

Custody Status:

What is the custody location?

Has the matter been previously adjourned?

If 'Yes', how many times?

Is an adjournment required?

If 'Yes', please select all that apply:

1 - Charge(s):

1 - Informant's Given Name(s):

1 - Informant's Surname:

1 - VP #:

1 - Station:

2 - Charge(s):

2 - Informant's Given Name(s):

2 - Informant's Surname:

2 - VP #:

2 - Station:

3 - Charge(s):

3 - Informant's Given Name(s):

3 - Informant's Surname:

3 - VP #:

3 - Station:

1 - Other Party's Given Name(s):

1 - Other Party's Surname:

1 - Other Party's Date of Birth:

2 - Other Party's Given Name(s):

2 - Other Party's Surname:

2 - Other Party's Date of Birth:

1 - Given Name(s) of Co-Accused:

1 - Surname of Co-Accused:

1 - Date of Birth of Co-Accused:

2 - Given Name(s) of Co-Accused:

2 - Surname of Co-Accused:

2 - Date of Birth of Co-Accused:

Is there a conflict of interest?

If 'Yes', please provide details of the conflict:

If 'Not applicable', please provide the reason:

Conflict check completed by:

Conflict Check Date:

Notes:

Referral required?

If 'Yes', why?

Have you previously approached and/or been refused assistance from another legal organisation?

If 'Yes', please provide details:

Referral made to:

Date of Referral to Other ALS / Spoken to:

Date of Referral to CLC / Spoken to:

Date of Referral to VLA / Spoken to:

Date of Referral to Private Practitioner / Spoken to:

Name of Referral Organisation 1:

Referral made to Organisation 1?

Date of Referral to Organisation 1:

Call back required?

Name of Referral Organisation 2:

Referral made to Organisation 2?

Date of Referral to Organisation 2:

Call back required?

Name of Referral Organisation 3:

Referral made to Organisation 3?

Date of Referral to Organisation 3:

Call back required?

Name of Referral Organisation 4:

Referral made to Organisation 4?

Date of Referral to Organisation 4:

Call back required?

Name of Referral Organisation 5:

Referral made to Organisation 5?

Date of Referral to Organisation 5:

Call back required?

To do list:

Authorised By:

Date Authorised: