Wirraway Enquiry Client Intake Form

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

Date of First Contact:

Intake Provided By:

Limitation Date:

Client Advised of Limitation Date:

Critical Date:

Type of Critical Date:

If 'Other', please specify:

Referral (if applicable):

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

Client Given Name(s):

Client Surname:

Preferred Name:

Other Known Name:

Date of Birth:

Gender:

Home Phone:

Mobile Phone:

Residential Address (Line 1):

Residential Address (Line 2):

Suburb:

Postcode:

State:

Country:

Email Address:

Tick if Postal Address same as Residential Address:

Postal Address (Line 1):

Postal Address (Line 2):

Suburb:

Postcode:

State:

Country:

Authorised Person's Name:

Authorised Person's Relationship to Client:

Authorised Person's Contact Number:

Aboriginality - Client is:

CoA on DB?

COA Certificate Supplied?

Internal CoA?

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):

If 'Other', please provide details:

Is your gross household income below $52,000?

Income Level (weekly/annual):

Centrelink (type of benefit):

CRN:

Form A required?

Form B required?

Priority Client Indicators:

Matter Category:

If 'Other', please provide details:

Conflict Check Completed By:

Date of Conflict Check:

Is there a Conflict?

If there is a conflict, please provide details here:

Authorisation to run conflict check with Civil Law, Family Law and Criminal Law:

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: