Duty Lawyer CLASS form (INTERNAL ONLY)

Date

"Before we start, I need to let you know that any personal information you provide to us including and similar to your name, address, telephone number and e-mail address will not be released, sold, or rented to any entities or individuals outside of Women’s Legal Service Victoria. Women’s Legal Service Victoria will only use the personal information provided by you for the purposes for which it was collected, and any other authorised use. The information Women’s Legal Service Victoria collects may also be used for its own planning and research purposes to improve its services. Are you happy to continue?"

Duty/Roster Lawyer first name

Duty/Roster Lawyer last name

Client first name

Client last name

Client date of birth

Client other names or DOB used

Please ask for all previous names for a complete conflict check. The client may have changed names due to marriage, choice or have a dead name. If no other names used, please write NA

Client gender identity

Client gender self-described

Please write NA if already described above

Client pronouns

Client street address

If the client is homeless, please write 'Homeless' here

Client suburb

Client postcode

Client state

Client phone number

Client email address

Is it safe for us to call you on the phone number you have given us?

When is a safe time to call you? If it is not safe to call you, please tell us and we will be in touch by email to make alternative arrangements

Is it safe for us to leave you a voicemail?

Is it safe for us to send you an SMS?

Is it safe for us to send an email to you?

Other party #1 first name

Other party #1 last name

Other party #1 date of birth

If the date of birth is unknown or a guesstimate, please write 1/1/[year]and make a file note to reflect your instructions.

Client's current relationship status

What is the first name of your current partner?

If the client's current partner is the other party, or if they do not have a current partner, you can leave this blank

What is the last name of your current partner?

If not applicable, leave blank as previous question

Date of birth of current partner

Child #1 first name

Child #1 last name

Child #1 date of birth

Names and dates of birth of any other children

If there are no other children, please leave blank. For each child, these details will need to be added as individual contacts on Actionstep

Conflict Check Outcome

Date of conflict check

Conflict check notes

Cultural Identity

Do you consider yourself to have a disability, impairment or long term condition?

If the disability type is not listed above, please provide details here

Client country of birth

What year did you arrive in Australia?

Client's main language spoken

If the client's main language spoken is not listed above, please specify the language here

Do you require an interpreter?

Client's country of citizenship

Residency status

Are you currently working?

Are you receiving Centrelink benefits? If yes, what type of payment are you receiving?

Where does your income come from?

Income per week after tax

If there is an important or limitation date, what is the date?

Date advised (if applicable)

This is only applicable to limitation dates

Important/limitation date notes

Family violence indicator

Homelessness status

Financial Disadvantage Indicator

At Women's Legal Service Victoria we like to give client's the opportunity to provide feedback about how we have helped them. Is the client ok with someone from Women's Legal Service Victoria contacting them to complete a short survey about how we have helped them? If the client changes their mind later on, the client does not have to complete the survey.

We will be keeping any notes and information related to this appointment for 7 years. After this we will destroy it. Does the client agree to us destroying our records in 7 years time?

WLSV Funding category

For ERS: select Early Resolution Service; For MMC: select Generalist

Service Type

For ERS: select Legal Advice; for MMC: select Duty Lawyer

What was the main problem type of the client's matter?

This is a multi select field. Always select Family or domestic violence order plus any other relevant problem type

Which court did you attend?

Legal Issues

ERS Notes

Duty Service Notes

Duty Lawyer CLASS form (INTERNAL ONLY)

Contact us

Our office is closed