Please note – This form is to facilitate the capturing of intake and service provision information. Date of First Contact: Intake Provided By: Please select VALS Lawyer Paralegal CSO Secretary Volunteer/Other Limitation Date: Client Advised of Limitation Date: Critical Date: Type of Critical Date: Please select Court Tribunal Other If 'Other', please specify: Referral (if applicable): Please Select Indigenous legal service assistance service Community legal service provider Family violence prevention legal service Legal aid commission Pro bono service Fee paying service Not known Court/Tribunal Family relationship centre Family dispute resolution centre Domestic violence support service Family support service Financial counselling service Health Service Housing Service Mental Health Service Other Has the person been represented by any of the other legal teams (Criminal, Family or Civil) and, if so, in what capacity? Does the person have related matters with Wirraway? Tub Placement of Form Post Database Entry Please select VALS to Follow Up Assisted Referral Awaiting Info From Client Bring To Case Plan Client Given Name(s): Client Surname: Preferred Name: Other Known Name: Date of Birth: Gender: Please select Male Female X (not male or female) Transgender Intersex or Indeterminate Other Unknown Home Phone: Mobile Phone: 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 Email Address: Tick if Postal Address same as Residential Address: Postal Address (Line 1): Postal 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 Authorised Person's Name: Authorised Person's Relationship to Client: Authorised Person's Contact Number: Aboriginality - Client is: Please select Aboriginal Torres Strait Islander Both CoA on DB? Please select Yes No COA Certificate Supplied? Please select Yes No Internal CoA? Please select Yes No If 'Yes', date of Internal CoA: Father: (for Internal CoA) Mother: (for Internal CoA) Paternal Grandfather: (for Internal CoA) Paternal Grandmother: (for Internal CoA) Maternal Grandfather: (for Internal CoA) Maternal Grandmother: (for Internal CoA) Mob/Tribe: (for Internal CoA) Disabilities (please select all that apply): Please Select Acquired Brain Injury Intellectual Neurological Physical Psychosocial Sensory Other If 'Other', please provide details: Is your gross household income below $52,000? Please select Yes No Income Level (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) Centrelink (type of benefit): Please Select ABSTUDY/AUSTUDY Aged pension Disability Parenting Veterans Youth Allowance CRN: Form A required? Please Select Yes No Form B required? Please Select Yes No Priority Client Indicators: Please select Family Violence In Custody Disability/Mental Illness Homelessness Low Education Level Single Parents Low proficiency English Rural or Remote Clients Children/Youths Older People Not Applicable Matter Category: Please Select Civil Litigation Coronial Inquest Deceased Estate Defamation Discrimination/Human Rights FOI Intentional Torts Other Medical Negligence Native Title Negligence Personal Injury Police Complaints Police Torts Prisoner Release Prisoner Complaints If 'Other', please provide details: Conflict Check Completed By: Date of Conflict Check: Is there a Conflict? Please select Yes No If there is a conflict, please provide details here: Authorisation to run conflict check with Civil Law, Family Law and Criminal Law: Please select Yes No Given Name(s) of Other Party 1: Surname of Other Party 1: Home Phone Number of Other Party 1: Mobile Phone Number of Other Party 1: Work Phone Number of Other Party 1: Address (Line 1) of Other Party 1: Address (Line 2) of Other Party 1: Suburb: Postcode: State: Country: Given Name(s) of Other Party 2: Surname of Other Party 2: Home Phone Number of Other Party 2: Mobile Phone Number of Other Party 2: Work Phone Number of Other Party 2: Address (Line 1) of Other Party 2: Address (Line 2) of Other Party 2: Suburb: Postcode State: Country: Intake Notes: Outcome: Authorised By: Date Authorised: