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: Please select Male Female X (not male or female) Transgender Intersex or Indeterminate Other Unknown Date of Birth: Date of birth is an estimate: Mobile: Other phone: Email: How can we contact you? Please select Mobile SMS Other phone Email How did you know about VALS Criminal Law team? Please select Previous client Referral from Community Referral (Family or Friend) Other 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? Please select Yes No At risk of Unknown Residential Address (Line 1): Residential Address (Line 2): Suburb: Postcode: State: Country: Australia New Zealand Austria Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua & Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bailiwick of Guernsey Bailiwick of Jersey Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo, Democratic Republic of Congo, Republic of Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland Former Yugoslavia France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Islamic Republic of Iran Isle of Man Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic Peoples Republic of Korea, Republic of Kosovo Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthélemy Saint Lucia Saint Martin Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka St. Helena St. Kitts and Nevis St. Pierre & Miquelon St. Vincent & the Grenadines Sudan Suriname Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, ROC Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Virgin Islands Unknown/Other Uruguay USA Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Wallis & Futuna Islands Western Sahara Yemen Zaire Zambia Zimbabwe Tick if your postal address is the same as the above: Postal Address (if different from residential address): Suburb: Postcode: State: Country: Australia New Zealand Austria Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua & Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bailiwick of Guernsey Bailiwick of Jersey Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo, Democratic Republic of Congo, Republic of Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland Former Yugoslavia France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Islamic Republic of Iran Isle of Man Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic Peoples Republic of Korea, Republic of Kosovo Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthélemy Saint Lucia Saint Martin Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka St. Helena St. Kitts and Nevis St. Pierre & Miquelon St. Vincent & the Grenadines Sudan Suriname Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, ROC Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Virgin Islands Unknown/Other Uruguay USA Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Wallis & Futuna Islands Western Sahara Yemen Zaire Zambia Zimbabwe Authorised person (OPTIONAL): Relationship (OPTIONAL): Phone (OPTIONAL): Do you require an interpreter? Please select Yes (Spoken language other than English) Yes (non-spoken communication) No If 'Yes', which language? Rating of your writing skills? Please select Very Well Well Not Well Not at all Not stated / inadequately described Rating of your spoken English skills? Please select Very Well Well Not Well Not at all Not stated / inadequately described Do you have a disability or mental health issues? Please select Yes No Unknown If 'Yes', please select all disabilities that apply: Please select Acquired Brain Injury Intellectual Neurological Physical Psychosocial Sensory Other No Disability If you have a hearing disability, would you like us to contact you through the National Relay Service? Please select Yes No Are you Aboriginal and/or Torres Strait Islander? Please select No Yes, Aboriginal Yes, Torres Strait Islander Yes, both Not Stated / inadequately described Please select type of CoA provided: Please select CoA Certificate Statutory Declaration Internal CoA 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): Family Violence In Custody Disability/Mental Illness Homelessness Low Education Level Single Parents Low proficiency English Rural or Remote Clients Children/Youths Older People COVID Not Applicable 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? Please select Yes No What is your Centrelink Customer Reference Number (CRN)? What type of benefit do you receive? Please select Abstudy Age Pension Disability support Newstart allowance Parenting payment Veterans benefit Youth allowance Other If 'Other', please provide details: Is this your main source of income? Please select Yes No What is your relationship status? Please select Married (registered or de facto) Never Married Divorced Separated Widowed Not Stated / Inadequately described What is your gross household income (weekly/annual)? Please select Negative income Nil income $1-199 ($1-$10,399) $200-$299 ($10,400-$15,599) $300-$399 ($15,600-$20,799) $400-$599 ($20,800-$31,199) $600-$799 ($31,200-$41,599) $800-$999 ($41,600-$51,999) $1000-$1249 ($52,000-$64,999) $1250-$1499 ($65,000-$77,999) $1500-$1999 ($78,000-$103,999) $2000 or more ($104,000 or more) 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)? Please select Yes No Do you have access to your finances at the moment? Please select Yes No, I cannot access my finances temporarily Court date: Court location: Court: Please select Children's Court Coroner's Court District Court Drug Court Family Court Family Violence Court Federal Circuit Court Federal Court High Court Indigenous Court Magistrates Court Mental Health Court Royal Commission Supreme Court Tribunal Other Non Court Matter If 'Other', please provide details: Hearing type: Please select Appeal Indictable Inquest Inquiry Interim Royal Commission Summary Trial Other Non-Court Matter Custody Status: Please select Breach bail In custody - charged In custody first instance warrant (nonappearance) or warrant of arrest of offence In custody on breach of Family Law Court order In custody on extradition warrant In custody on parole warrant pending determination of breach In custody - remanded/unsentenced In custody - sentenced In custody - uncharged In custody under Mental Health Act or Guardianship In custody under Part 8A CLC Act - unfitness to plead In custody under Public Intoxication Act Not in custody, summons to appear On bail What is the custody location? Please select Melbourne Custody Centre Metropolitan Remand Centre Melbourne Assessment Prison Port Phillip Prison Dame Phyllis Frost Centre Dhurringile Prison Fulham Correctional Centre Loddon Prison Barwon Prison Middelton Prison Malmsbury Youth Justice Centre Parkville Youth Justice Centre Wulgunggo Ngalu Learning Place Bunjilwarra Hopkins Correctional Centre Langi Kal Kal Prison Beechworth Correctional Centre Marngoneet Correctional Centre Tarrengower Prison Mildura Police Station Raven Hall Has the matter been previously adjourned? Please select Yes No If 'Yes', how many times? Is an adjournment required? Please select Yes No If 'Yes', please select all that apply: Please select The court date is not a VALS date The client has provided consent to adjourn the matter Adjournment request has been sent 1 - Charge(s): Please Select Abduction of a Child Under the Age of 16 for Sex Abduction or Detention for Sex Abortion Accessibility of Records for Tax Department Additional Records for Taxation Administration of Drugs for Sex Affray Aggravated Animal Cruelty Aggravated Assault Aggravated Burglary Aggravated Carjacking Aggravated Home Invasion Aiding and Abetting offences Ammunition – Possessing, Acquiring or Carrying Animal Cruelty Armed Robbery Arson Arson Causing Death Assault Assault Emergency Worker Assault With Intent to Rape Assault with weapon Assaulting or Resisting Police Being Disguised With Unlawful Intent Bestiality Bigamy Blackmail Bomb Hoaxes Breach of Bail Breach of an Intervention Order Breach of Community Corrections Order Breach of Suspended Sentence Burglary Carjacking Careless Driving Carry dangerous article Causing Injury Intentionally Causing Injury Recklessly Causing Serious Injury Intentionally in Circumstances of Gross Violence Causing Serious Injury Recklessly in Circumstances of Gross Violence Collecting or Making Documents Likely to Facilitate Terrorist Acts Common Assault Common Assault (Common Law) Compelling Sexual Penetration Concealing birth of a child Consequences of Failing to Comply With Section 260A Consorting Conspiracy (Common Law) Contaminating Goods Causing Public Alarm or Economic Loss Contempt of Court Contravene Family Violence Order Control of Body Armour Control of Use of Dangerous Articles Corporate Criminal Responsibility for Offence Against Section 254 Corrupting Benefits Given To, or Received By, a Commonwealth Public Official Criminal Damage Culpable Driving Causing Death Cultivation of Narcotic Plants Cultivation of Narcotic Plants – Commercial Quantity Cultivation of Narcotic Plants – Large Commercial Quantity Dangerous Driving Dangerous Driving Causing Death or Serious Injury Dangerous Driving while pursued by police Dangerous Goods on Aircraft Dealing With Property Suspected of Being Proceeds of Crime Dealing With Property Which Subsequently Becomes an Instrument of Crime Delay Entry of Police Deliberately Omitting Information Destroying or Damaging Commonwealth Property Destroying or Damaging Property Destruction of Evidence Directing the Activities of a Terrorist Organisation Directors Must Give Information to Company Discharge missile causing injury Dishonestly Cause a Loss Dishonestly Obtain a Financial Advantage (Centrelink Fraud) Disturbing Religious Worship Drink Driving Exceed PCA Drive While Impaired By Drugs (Drug Driving) Driving a Motor Vehicle When Directed to Stop By Police Driving Disqualified Driving Under the Influence of Intoxicating Liquor or of Any Drug Driving While Exceeding the Prescribed Concentration of Alcohol Driving While Licence Suspended Under Infringements Act 2006 Drunk in Public Drunkards Behaving in Riotous or Disorderly Manner Duty of Driver etc. of Vehicle That is Not a Motor Vehicle If Accident Occurs Duty of Driver, etc. of Motor Vehicle If Accident Occurs Duty of Owner of Motor Vehicle to Give Information About Driver Endangering Safe Operation of an Aircraft Endangering Safety of Aircraft Entering a Level Crossing When a Train or Tram is Approaching Escaping From Lawful Custody Exceed PCA Exceed Prescribed Concentration of Drugs Exceed Prescribed Concentration of Drugs (Drug Driving) Extortion With Threats to Destroy Property Extortion With Threats to Kill Faciliting sexual offences agasinst children Fail by person in authority to protect child from sexual offence Failure of Directors to Call General Meeting Failure of Responsible Entity to Call Meeting of the Scheme’s Members Failure to Answer Bail Failure to Answer Questions When Attending Before the Commissioner Failure to Comply With Requirements Under Taxation Law Failure to Lodge Documents False Accounting False Imprisonment False or Misleading Information False Statements False Statements By Company Directors Falsification of Documents Falsifying or Concealing Identity Forgery Forgery etc. of Documents and Identification Marks Forging Prescriptions and Orders for Drugs of Dependence Form of Record – English Language Frauds By Officers Furnish False or Misleading Information (Sex Offender Registry) General Duty of Driver or Person in Charge of Motor Vehicle Getting Funds To, From, or For a Terrorist Organisation Giving False or Misleading Information to Tax Officers Going Equipped for Stealing Good Faith, Use of Position and Use of Information – Criminal Offences Grooming for sexual conduct with a child under the age of 16 years Handeling Stolen goods Infringements Home Invasion Importing and Exporting Border Controlled Precursors Importing and Exporting Commercial Quantities of Border Controlled Drugs or Border Controlled Plants Improper Use of Motor Vehicle Incest Incitment Inclusion of False or Misleading Information in Records Incurring of Certain Debts; Fraudulent Conduct Indecent Act With a Child Under the Age of 16 Indecent Act With a Child 16 to 17 Years old Indecent Assault Indemnifying Surety Inducement to Be Appointed Liquidator etc. of Company Infanticide Insider Trading Intentionally Causing a Serious Disease Intentionally Causing Serious Injury Intentionally or Recklessly Causing a Bushfire Interfere With Corpse of a Human Being Interfering With Political Liberty Introduction of a Drug of Dependence Into the Body of Another Person Kidnapping Lighting of Fires in the Open Air Listed Company – Director to Notify Market Operator of Shareholdings etc. Loitering Near Schools Loitering With Intent to Commit an Indictable Offence Making False Reports to Police etc. Manslaughter Material Personal Interest – Director’s Duty to Disclose Membership of a Terrorist Organisation Murder Negligently Causing Serious Injury Notice to ASIC of Share Cancellation Notice to ASIC of Share Issue Obscene Exposure Obscene, Indecent, Threatening Language and Behaviour in Public Obstruction of Commissioner or an Authorised Officer Obstruction of Commonwealth Public Officials Obtain a Financial Advantage By Deception (Commonwealth) (Common Centrelink Charge) Obtaining Drugs of Dependence By False Representation Obtaining Financial Advantage By Deception Obtaining Licence etc. By False Statements Obtaining Property By Deception Obtaining Property By Deception – Commonwealth Occupier etc. Permitting Unlawful Sexual Penetration Offence of Serious Racial Vilification Offence to Alter, Deface or Place Number on Engine of Motor Vehicle Offence to Harass Witnesses etc. Offence to Obstruct etc. Person Operating Road Safety Camera or Speed Detector Offence to Procure Use of Motor Vehicle By Fraud Offence to Provide False or Misleading Information Offence to Sell Certain Breath Analysing Instruments Offences Against Court Security Offences By Officers of Certain Companies Offences By Persons Involved in Management of Bodies Corporate Offences Connected With Explosive Substances Offences for Failure to Comply With Statutory Duties Offences for Failure to Comply With Statutory Duties By Guarantor Offensive Behaviour By a Person in a Motor Vehicle in a Declared Area Other Acts Done in Preparation for, or Planning, Terrorist Acts Period of Retention Perjury Persistent Sexual Abuse of a Child Under the Age of 16 Persons Found Drunk and Disorderly Perverting the Course of Justice Police Bribery and Corruption Possess Property Reasonably Suspected to be Stolen Possessing a Longarm Without License Possessing an Unregistered Longarm Possessing Certain Types of Handguns Possess Cannabis Possessing Controlled Drugs Possessing Controlled Precursors Possessing Controlled Weapon Possessing Housebreaking Implements Possessing Marketable Quantities of Unlawfully Imported Border Controlled Drugs or Border Controlled Plants Possessing Things Connected With Terrorist Attacks Possessing Trafficable Quantity of Unregistered Firearms Possessing Unlawfully Imported Border Controlled Drugs Or Border Controlled Plants Possessing, Carrying or Using a Handgun Without a Licence (Non-prohibited Person) Possessing, Using, or Carrying an Unregistered Handgun Possession of a Drug of Dependence Possession of Child Pornography Possession of Data With Intent to Commit Serious Computer Offence Possession of Precursor Chemicals Possession of Substance etc for Trafficking in a Drug of Dependence Possession of Tablet Press Posting Bills and Defacing Property Procurement etc. of Minor for Child Pornography Procuring Sexual Penetration By Threats or Fraud Procuring Sexual Penetration of a Child Producing, Supplying or Obtaining Data With Intent to Commit Serious Computer Offence Production of Child Pornography Prohibited Person Possessing Firearms Prohibited Weapons Providing or Receiving Training Connected With Terrorist Acts Public Nuisance Rape Reckless Conduct Endangering Life Reckless Conduct Endangering Serious Injury Recklessly cause injury Recklessly Causing Serious Injury Recruiting for a Terrorist Organisation Refuse Breath Test – Drink Driving Refuse Drug Test – Drug Driving Refuse to Give Blood or Urine Sample – Drink Driving Refuse to Provide Further Sample – Drink Driving Refuse to Provide Oral Fluid – Drink Driving Refuse to Stop Requirement to Keep Proper Records Resisting Arrest Riot Rioters Demolishing Buildings Robbery Rout Sabotage Setting Fire to Aircraft Setting Traps to Kill Sex Offender Registry – Failing to Comply With Reporting Conditions Sexual Assault Sexual Offences – Persons With a Cognitive Impairment By Providers of Special Programs Sexual Offences Against Persons With a Cognitive Impairment By Doctors etc Sexual Offence while armed Sexual Penetration of 16 or 17 Year Old Child Sexual Penetration of a Child Under the Age of 16 Sexual Servitude Shop steal (theft) Speed Trials Stalking Supply of Drug of Dependence to a Child Supplying Drugs to Children Suppression of Documents Taking or Use Vehicle Without Owner’s Consent Tampering or Interfering With Motor Vehicle Without Just Cause or Excuse Tax Evasion Terrorist Acts Theft – Commonwealth Theft (State) Theft of a bicycle Theft of a firearm Theft of Motor Vehicle Theft from Motor Vehicle Threatening Injury to Prevent Arrest Threatening to Contaminate Goods Threats to commit a sexual assault Threats to Destroy or Damage Property Threats to Inflict Serious Injury Threats to Kill Threats to Sabotage Threats to Safety of Aircraft Trafficking in a Drug of Dependence Trafficking in a Drug of Dependence to a Child Trafficking in a Drug or Drugs of Dependence – Commercial Quantity Trafficking in a Drug or Drugs of Dependence – Large Commercial Quantity Trespass Unauthorised Access to or Modification of Restricted Data Unauthorised Access, Modification or Impairment With Intent to Commit a Serious Offence Unauthorised Impairment of Data Held in Computer Disk, Credit Dard or Other Device Unauthorised Impairment of Electronic Communication – Commonwealth Unauthorised Impairment of Electronic Communication – State Unauthorised Modification of Data to Cause Impairment – State Unauthorised Modification of Data to Cause Impairment – Commonwealth Unlawful Assembly Unlawful Oaths to Commit Treason, Murder etc. Unlawfully Taking Control of an Aircraft Unlicensed Driving Use of a Drug of Dependence Using Firearms to Resist Arrest Using of Firearms in the Commission of Offences Wilful Damage Wilfully Destroying Records 1 - Informant's Given Name(s): 1 - Informant's Surname: 1 - VP #: 1 - Station: 2 - Charge(s): Please select Abduction of a Child Under the Age of 16 for Sex Abduction or Detention for Sex Abortion Accessibility of Records for Tax Department Additional Records for Taxation Administration of Drugs for Sex Affray Aggravated Animal Cruelty Aggravated Assault Aggravated Burglary Aggravated Carjacking Aggravated Home Invasion Aiding and Abetting offences Ammunition – Possessing, Acquiring or Carrying Animal Cruelty Armed Robbery Arson Arson Causing Death Assault Assault Emergency Worker Assault With Intent to Rape Assault with weapon Assaulting or Resisting Police Being Disguised With Unlawful Intent Bestiality Bigamy Blackmail Bomb Hoaxes Breach of Bail Breach of an Intervention Order Breach of Community Corrections Order Breach of Suspended Sentence Burglary Carjacking Careless Driving Carry dangerous article Causing Injury Intentionally Causing Injury Recklessly Causing Serious Injury Intentionally in Circumstances of Gross Violence Causing Serious Injury Recklessly in Circumstances of Gross Violence Collecting or Making Documents Likely to Facilitate Terrorist Acts Common Assault Common Assault (Common Law) Compelling Sexual Penetration Concealing birth of a child Consequences of Failing to Comply With Section 260A Consorting Conspiracy (Common Law) Contaminating Goods Causing Public Alarm or Economic Loss Contempt of Court Contravene Family Violence Order Control of Body Armour Control of Use of Dangerous Articles Corporate Criminal Responsibility for Offence Against Section 254 Corrupting Benefits Given To, or Received By, a Commonwealth Public Official Criminal Damage Culpable Driving Causing Death Cultivation of Narcotic Plants Cultivation of Narcotic Plants – Commercial Quantity Cultivation of Narcotic Plants – Large Commercial Quantity Dangerous Driving Dangerous Driving Causing Death or Serious Injury Dangerous Driving while pursued by police Dangerous Goods on Aircraft Dealing With Property Suspected of Being Proceeds of Crime Dealing With Property Which Subsequently Becomes an Instrument of Crime Delay Entry of Police Deliberately Omitting Information Destroying or Damaging Commonwealth Property Destroying or Damaging Property Destruction of Evidence Directing the Activities of a Terrorist Organisation Directors Must Give Information to Company Discharge missile causing injury Dishonestly Cause a Loss Dishonestly Obtain a Financial Advantage (Centrelink Fraud) Disturbing Religious Worship Drink Driving Exceed PCA Drive While Impaired By Drugs (Drug Driving) Driving a Motor Vehicle When Directed to Stop By Police Driving Disqualified Driving Under the Influence of Intoxicating Liquor or of Any Drug Driving While Exceeding the Prescribed Concentration of Alcohol Driving While Licence Suspended Under Infringements Act 2006 Drunk in Public Drunkards Behaving in Riotous or Disorderly Manner Duty of Driver etc. of Vehicle That is Not a Motor Vehicle If Accident Occurs Duty of Driver, etc. of Motor Vehicle If Accident Occurs Duty of Owner of Motor Vehicle to Give Information About Driver Endangering Safe Operation of an Aircraft Endangering Safety of Aircraft Entering a Level Crossing When a Train or Tram is Approaching Escaping From Lawful Custody Exceed PCA Exceed Prescribed Concentration of Drugs Exceed Prescribed Concentration of Drugs (Drug Driving) Extortion With Threats to Destroy Property Extortion With Threats to Kill Faciliting sexual offences agasinst children Fail by person in authority to protect child from sexual offence Failure of Directors to Call General Meeting Failure of Responsible Entity to Call Meeting of the Scheme’s Members Failure to Answer Bail Failure to Answer Questions When Attending Before the Commissioner Failure to Comply With Requirements Under Taxation Law Failure to Lodge Documents False Accounting False Imprisonment False or Misleading Information False Statements False Statements By Company Directors Falsification of Documents Falsifying or Concealing Identity Forgery Forgery etc. of Documents and Identification Marks Forging Prescriptions and Orders for Drugs of Dependence Form of Record – English Language Frauds By Officers Furnish False or Misleading Information (Sex Offender Registry) General Duty of Driver or Person in Charge of Motor Vehicle Getting Funds To, From, or For a Terrorist Organisation Giving False or Misleading Information to Tax Officers Going Equipped for Stealing Good Faith, Use of Position and Use of Information – Criminal Offences Grooming for sexual conduct with a child under the age of 16 years Handeling Stolen goods Infringements Home Invasion Importing and Exporting Border Controlled Precursors Importing and Exporting Commercial Quantities of Border Controlled Drugs or Border Controlled Plants Improper Use of Motor Vehicle Incest Incitment Inclusion of False or Misleading Information in Records Incurring of Certain Debts; Fraudulent Conduct Indecent Act With a Child Under the Age of 16 Indecent Act With a Child 16 to 17 Years old Indecent Assault Indemnifying Surety Inducement to Be Appointed Liquidator etc. of Company Infanticide Insider Trading Intentionally Causing a Serious Disease Intentionally Causing Serious Injury Intentionally or Recklessly Causing a Bushfire Interfere With Corpse of a Human Being Interfering With Political Liberty Introduction of a Drug of Dependence Into the Body of Another Person Kidnapping Lighting of Fires in the Open Air Listed Company – Director to Notify Market Operator of Shareholdings etc. Loitering Near Schools Loitering With Intent to Commit an Indictable Offence Making False Reports to Police etc. Manslaughter Material Personal Interest – Director’s Duty to Disclose Membership of a Terrorist Organisation Murder Negligently Causing Serious Injury Notice to ASIC of Share Cancellation Notice to ASIC of Share Issue Obscene Exposure Obscene, Indecent, Threatening Language and Behaviour in Public Obstruction of Commissioner or an Authorised Officer Obstruction of Commonwealth Public Officials Obtain a Financial Advantage By Deception (Commonwealth) (Common Centrelink Charge) Obtaining Drugs of Dependence By False Representation Obtaining Financial Advantage By Deception Obtaining Licence etc. By False Statements Obtaining Property By Deception Obtaining Property By Deception – Commonwealth Occupier etc. Permitting Unlawful Sexual Penetration Offence of Serious Racial Vilification Offence to Alter, Deface or Place Number on Engine of Motor Vehicle Offence to Harass Witnesses etc. Offence to Obstruct etc. Person Operating Road Safety Camera or Speed Detector Offence to Procure Use of Motor Vehicle By Fraud Offence to Provide False or Misleading Information Offence to Sell Certain Breath Analysing Instruments Offences Against Court Security Offences By Officers of Certain Companies Offences By Persons Involved in Management of Bodies Corporate Offences Connected With Explosive Substances Offences for Failure to Comply With Statutory Duties Offences for Failure to Comply With Statutory Duties By Guarantor Offensive Behaviour By a Person in a Motor Vehicle in a Declared Area Other Acts Done in Preparation for, or Planning, Terrorist Acts Period of Retention Perjury Persistent Sexual Abuse of a Child Under the Age of 16 Persons Found Drunk and Disorderly Perverting the Course of Justice Police Bribery and Corruption Possess Property Reasonably Suspected to be Stolen Possessing a Longarm Without License Possessing an Unregistered Longarm Possessing Certain Types of Handguns Possess Cannabis Possessing Controlled Drugs Possessing Controlled Precursors Possessing Controlled Weapon Possessing Housebreaking Implements Possessing Marketable Quantities of Unlawfully Imported Border Controlled Drugs or Border Controlled Plants Possessing Things Connected With Terrorist Attacks Possessing Trafficable Quantity of Unregistered Firearms Possessing Unlawfully Imported Border Controlled Drugs Or Border Controlled Plants Possessing, Carrying or Using a Handgun Without a Licence (Non-prohibited Person) Possessing, Using, or Carrying an Unregistered Handgun Possession of a Drug of Dependence Possession of Child Pornography Possession of Data With Intent to Commit Serious Computer Offence Possession of Precursor Chemicals Possession of Substance etc for Trafficking in a Drug of Dependence Possession of Tablet Press Posting Bills and Defacing Property Procurement etc. of Minor for Child Pornography Procuring Sexual Penetration By Threats or Fraud Procuring Sexual Penetration of a Child Producing, Supplying or Obtaining Data With Intent to Commit Serious Computer Offence Production of Child Pornography Prohibited Person Possessing Firearms Prohibited Weapons Providing or Receiving Training Connected With Terrorist Acts Public Nuisance Rape Reckless Conduct Endangering Life Reckless Conduct Endangering Serious Injury Recklessly cause injury Recklessly Causing Serious Injury Recruiting for a Terrorist Organisation Refuse Breath Test – Drink Driving Refuse Drug Test – Drug Driving Refuse to Give Blood or Urine Sample – Drink Driving Refuse to Provide Further Sample – Drink Driving Refuse to Provide Oral Fluid – Drink Driving Refuse to Stop Requirement to Keep Proper Records Resisting Arrest Riot Rioters Demolishing Buildings Robbery Rout Sabotage Setting Fire to Aircraft Setting Traps to Kill Sex Offender Registry – Failing to Comply With Reporting Conditions Sexual Assault Sexual Offences – Persons With a Cognitive Impairment By Providers of Special Programs Sexual Offences Against Persons With a Cognitive Impairment By Doctors etc Sexual Offence while armed Sexual Penetration of 16 or 17 Year Old Child Sexual Penetration of a Child Under the Age of 16 Sexual Servitude Shop Steal (theft) Speed Trials Stalking Supply of Drug of Dependence to a Child Supplying Drugs to Children Suppression of Documents Taking or Use Vehicle Without Owner’s Consent Tampering or Interfering With Motor Vehicle Without Just Cause or Excuse Tax Evasion Terrorist Acts Theft – Commonwealth Theft (State) Theft of a bicycle Theft of a firearm Theft of Motor Vehicle Theft from Motor Vehicle Threatening Injury to Prevent Arrest Threatening to Contaminate Goods Threats to commit a sexual assault Threats to Destroy or Damage Property Threats to Inflict Serious Injury Threats to Kill Threats to Sabotage Threats to Safety of Aircraft Trafficking in a Drug of Dependence Trafficking in a Drug of Dependence to a Child Trafficking in a Drug or Drugs of Dependence – Commercial Quantity Trafficking in a Drug or Drugs of Dependence – Large Commercial Quantity Trespass Unauthorised Access to or Modification of Restricted Data Unauthorised Access, Modification or Impairment With Intent to Commit a Serious Offence Unauthorised Impairment of Data Held in Computer Disk, Credit Dard or Other Device Unauthorised Impairment of Electronic Communication – Commonwealth Unauthorised Impairment of Electronic Communication – State Unauthorised Modification of Data to Cause Impairment – State Unauthorised Modification of Data to Cause Impairment – Commonwealth Unlawful Assembly Unlawful Oaths to Commit Treason, Murder etc. Unlawfully Taking Control of an Aircraft Unlicensed Driving Use of a Drug of Dependence Using Firearms to Resist Arrest Using of Firearms in the Commission of Offences Wilful Damage Wilfully Destroying Records 2 - Informant's Given Name(s): 2 - Informant's Surname: 2 - VP #: 2 - Station: 3 - Charge(s): Please select Abduction of a Child Under the Age of 16 for Sex Abduction or Detention for Sex Abortion Accessibility of Records for Tax Department Additional Records for Taxation Administration of Drugs for Sex Affray Aggravated Animal Cruelty Aggravated Assault Aggravated Burglary Aggravated Carjacking Aggravated Home Invasion Aiding and Abetting offences Ammunition – Possessing, Acquiring or Carrying Animal Cruelty Armed Robbery Arson Arson Causing Death Assault Assault Emergency Worker Assault With Intent to Rape Assault with weapon Assaulting or Resisting Police Being Disguised With Unlawful Intent Bestiality Bigamy Blackmail Bomb Hoaxes Breach of Bail Breach of an Intervention Order Breach of Community Corrections Order Breach of Suspended Sentence Burglary Carjacking Careless Driving Carry dangerous article Causing Injury Intentionally Causing Injury Recklessly Causing Serious Injury Intentionally in Circumstances of Gross Violence Causing Serious Injury Recklessly in Circumstances of Gross Violence Collecting or Making Documents Likely to Facilitate Terrorist Acts Common Assault Common Assault (Common Law) Compelling Sexual Penetration Concealing birth of a child Consequences of Failing to Comply With Section 260A Consorting Conspiracy (Common Law) Contaminating Goods Causing Public Alarm or Economic Loss Contempt of Court Contravene Family Violence Order Control of Body Armour Control of Use of Dangerous Articles Corporate Criminal Responsibility for Offence Against Section 254 Corrupting Benefits Given To, or Received By, a Commonwealth Public Official Criminal Damage Culpable Driving Causing Death Cultivation of Narcotic Plants Cultivation of Narcotic Plants – Commercial Quantity Cultivation of Narcotic Plants – Large Commercial Quantity Dangerous Driving Dangerous Driving Causing Death or Serious Injury Dangerous Driving while pursued by police Dangerous Goods on Aircraft Dealing With Property Suspected of Being Proceeds of Crime Dealing With Property Which Subsequently Becomes an Instrument of Crime Delay Entry of Police Deliberately Omitting Information Destroying or Damaging Commonwealth Property Destroying or Damaging Property Destruction of Evidence Directing the Activities of a Terrorist Organisation Directors Must Give Information to Company Discharge missile causing injury Dishonestly Cause a Loss Dishonestly Obtain a Financial Advantage (Centrelink Fraud) Disturbing Religious Worship Drink Driving Exceed PCA Drive While Impaired By Drugs (Drug Driving) Driving a Motor Vehicle When Directed to Stop By Police Driving Disqualified Driving Under the Influence of Intoxicating Liquor or of Any Drug Driving While Exceeding the Prescribed Concentration of Alcohol Driving While Licence Suspended Under Infringements Act 2006 Drunk in Public Drunkards Behaving in Riotous or Disorderly Manner Duty of Driver etc. of Vehicle That is Not a Motor Vehicle If Accident Occurs Duty of Driver, etc. of Motor Vehicle If Accident Occurs Duty of Owner of Motor Vehicle to Give Information About Driver Endangering Safe Operation of an Aircraft Endangering Safety of Aircraft Entering a Level Crossing When a Train or Tram is Approaching Escaping From Lawful Custody Exceed PCA Exceed Prescribed Concentration of Drugs Exceed Prescribed Concentration of Drugs (Drug Driving) Extortion With Threats to Destroy Property Extortion With Threats to Kill Faciliting sexual offences agasinst children Fail by person in authority to protect child from sexual offence Failure of Directors to Call General Meeting Failure of Responsible Entity to Call Meeting of the Scheme’s Members Failure to Answer Bail Failure to Answer Questions When Attending Before the Commissioner Failure to Comply With Requirements Under Taxation Law Failure to Lodge Documents False Accounting False Imprisonment False or Misleading Information False Statements False Statements By Company Directors Falsification of Documents Falsifying or Concealing Identity Forgery Forgery etc. of Documents and Identification Marks Forging Prescriptions and Orders for Drugs of Dependence Form of Record – English Language Frauds By Officers Furnish False or Misleading Information (Sex Offender Registry) General Duty of Driver or Person in Charge of Motor Vehicle Getting Funds To, From, or For a Terrorist Organisation Giving False or Misleading Information to Tax Officers Going Equipped for Stealing Good Faith, Use of Position and Use of Information – Criminal Offences Grooming for sexual conduct with a child under the age of 16 years Handeling Stolen goods Infringements Home Invasion Importing and Exporting Border Controlled Precursors Importing and Exporting Commercial Quantities of Border Controlled Drugs or Border Controlled Plants Improper Use of Motor Vehicle Incest Incitment Inclusion of False or Misleading Information in Records Incurring of Certain Debts; Fraudulent Conduct Indecent Act With a Child Under the Age of 16 Indecent Act With a Child 16 to 17 Years old Indecent Assault Indemnifying Surety Inducement to Be Appointed Liquidator etc. of Company Infanticide Insider Trading Intentionally Causing a Serious Disease Intentionally Causing Serious Injury Intentionally or Recklessly Causing a Bushfire Interfere With Corpse of a Human Being Interfering With Political Liberty Introduction of a Drug of Dependence Into the Body of Another Person Kidnapping Lighting of Fires in the Open Air Listed Company – Director to Notify Market Operator of Shareholdings etc. Loitering Near Schools Loitering With Intent to Commit an Indictable Offence Making False Reports to Police etc. Manslaughter Material Personal Interest – Director’s Duty to Disclose Membership of a Terrorist Organisation Murder Negligently Causing Serious Injury Notice to ASIC of Share Cancellation Notice to ASIC of Share Issue Obscene Exposure Obscene, Indecent, Threatening Language and Behaviour in Public Obstruction of Commissioner or an Authorised Officer Obstruction of Commonwealth Public Officials Obtain a Financial Advantage By Deception (Commonwealth) (Common Centrelink Charge) Obtaining Drugs of Dependence By False Representation Obtaining Financial Advantage By Deception Obtaining Licence etc. By False Statements Obtaining Property By Deception Obtaining Property By Deception – Commonwealth Occupier etc. Permitting Unlawful Sexual Penetration Offence of Serious Racial Vilification Offence to Alter, Deface or Place Number on Engine of Motor Vehicle Offence to Harass Witnesses etc. Offence to Obstruct etc. Person Operating Road Safety Camera or Speed Detector Offence to Procure Use of Motor Vehicle By Fraud Offence to Provide False or Misleading Information Offence to Sell Certain Breath Analysing Instruments Offences Against Court Security Offences By Officers of Certain Companies Offences By Persons Involved in Management of Bodies Corporate Offences Connected With Explosive Substances Offences for Failure to Comply With Statutory Duties Offences for Failure to Comply With Statutory Duties By Guarantor Offensive Behaviour By a Person in a Motor Vehicle in a Declared Area Other Acts Done in Preparation for, or Planning, Terrorist Acts Period of Retention Perjury Persistent Sexual Abuse of a Child Under the Age of 16 Persons Found Drunk and Disorderly Perverting the Course of Justice Police Bribery and Corruption Possess Property Reasonably Suspected to be Stolen Possessing a Longarm Without License Possessing an Unregistered Longarm Possessing Certain Types of Handguns Possess Cannabis Possessing Controlled Drugs Possessing Controlled Precursors Possessing Controlled Weapon Possessing Housebreaking Implements Possessing Marketable Quantities of Unlawfully Imported Border Controlled Drugs or Border Controlled Plants Possessing Things Connected With Terrorist Attacks Possessing Trafficable Quantity of Unregistered Firearms Possessing Unlawfully Imported Border Controlled Drugs Or Border Controlled Plants Possessing, Carrying or Using a Handgun Without a Licence (Non-prohibited Person) Possessing, Using, or Carrying an Unregistered Handgun Possession of a Drug of Dependence Possession of Child Pornography Possession of Data With Intent to Commit Serious Computer Offence Possession of Precursor Chemicals Possession of Substance etc for Trafficking in a Drug of Dependence Possession of Tablet Press Posting Bills and Defacing Property Procurement etc. of Minor for Child Pornography Procuring Sexual Penetration By Threats or Fraud Procuring Sexual Penetration of a Child Producing, Supplying or Obtaining Data With Intent to Commit Serious Computer Offence Production of Child Pornography Prohibited Person Possessing Firearms Prohibited Weapons Providing or Receiving Training Connected With Terrorist Acts Public Nuisance Rape Reckless Conduct Endangering Life Reckless Conduct Endangering Serious Injury Recklessly cause injury Recklessly Causing Serious Injury Recruiting for a Terrorist Organisation Refuse Breath Test – Drink Driving Refuse Drug Test – Drug Driving Refuse to Give Blood or Urine Sample – Drink Driving Refuse to Provide Further Sample – Drink Driving Refuse to Provide Oral Fluid – Drink Driving Refuse to Stop Requirement to Keep Proper Records Resisting Arrest Riot Rioters Demolishing Buildings Robbery Rout Sabotage Setting Fire to Aircraft Setting Traps to Kill Sex Offender Registry – Failing to Comply With Reporting Conditions Sexual Assault Sexual Offences – Persons With a Cognitive Impairment By Providers of Special Programs Sexual Offences Against Persons With a Cognitive Impairment By Doctors etc Sexual Offence while armed Sexual Penetration of 16 or 17 Year Old Child Sexual Penetration of a Child Under the Age of 16 Sexual Servitude Shop Steal (theft) Speed Trials Stalking Supply of Drug of Dependence to a Child Supplying Drugs to Children Suppression of Documents Taking or Use Vehicle Without Owner’s Consent Tampering or Interfering With Motor Vehicle Without Just Cause or Excuse Tax Evasion Terrorist Acts Theft – Commonwealth Theft (State) Theft of a bicycle Theft of a firearm Theft of Motor Vehicle Theft from Motor Vehicle Threatening Injury to Prevent Arrest Threatening to Contaminate Goods Threats to commit a sexual assault Threats to Destroy or Damage Property Threats to Inflict Serious Injury Threats to Kill Threats to Sabotage Threats to Safety of Aircraft Trafficking in a Drug of Dependence Trafficking in a Drug of Dependence to a Child Trafficking in a Drug or Drugs of Dependence – Commercial Quantity Trafficking in a Drug or Drugs of Dependence – Large Commercial Quantity Trespass Unauthorised Access to or Modification of Restricted Data Unauthorised Access, Modification or Impairment With Intent to Commit a Serious Offence Unauthorised Impairment of Data Held in Computer Disk, Credit Dard or Other Device Unauthorised Impairment of Electronic Communication – Commonwealth Unauthorised Impairment of Electronic Communication – State Unauthorised Modification of Data to Cause Impairment – State Unauthorised Modification of Data to Cause Impairment – Commonwealth Unlawful Assembly Unlawful Oaths to Commit Treason, Murder etc. Unlawfully Taking Control of an Aircraft Unlicensed Driving Use of a Drug of Dependence Using Firearms to Resist Arrest Using of Firearms in the Commission of Offences Wilful Damage Wilfully Destroying Records 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? Please select Yes No Not applicable 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? Please select Yes No If 'Yes', why? Have you previously approached and/or been refused assistance from another legal organisation? Please select Yes No If 'Yes', please provide details: Referral made to: Please select Other ALS CLC VLA Private Practitioner 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? Please select Yes No Date of Referral to Organisation 1: Call back required? Please select Yes No Name of Referral Organisation 2: Referral made to Organisation 2? Please select Yes No Date of Referral to Organisation 2: Call back required? Please select Yes No Name of Referral Organisation 3: Referral made to Organisation 3? Please select Yes No Date of Referral to Organisation 3: Call back required? Please select Yes No Name of Referral Organisation 4: Referral made to Organisation 4? Please select Yes No Date of Referral to Organisation 4: Call back required? Please select Yes No Name of Referral Organisation 5: Referral made to Organisation 5? Please select Yes No Date of Referral to Organisation 5: Call back required? Please select Yes No To do list: Authorised By: Date Authorised: