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 Lawyer first name

Duty Lawyer last name

Referrer's first name

Referrer's last name

Referrer's Organisation

Referrer's organisation phone number

Referrer's direct phone number

Referrer's email address

Client consent for referral?

Has the client been assisted by WLSV before?

Client first name

Client last name

Client date of birth

Client other names or DOB used

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 state

Client postcode

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?

Main language spoken

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

If this field is not applicable, please write NA

Do you require an interpreter?

Interpreter used?

Job/Reference number for interpreting service and interpreter name and language

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 write NA. These details will need to be added individually to Actionstep as contacts

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.

Names and dates of birth of any other parties

If there are no other other parties please write NA. These details will need to be added individually to Actionstep as contacts

What is the first name of your current partner?

If you do not have a current partner, please write 'not applicable'.

What is the last name of your current partner?

If you do not have a current partner, please write 'not applicable'.

What is the date of birth of your current partner?

Conflict check complete?

No conflict identified

Cultural Identity

Client country of birth

What year did you arrive in Australia?

If not applicable, write 'NA'

Country of citizenship

Residency status

If the client is on a Visa, or their Visa has expired, please ask the following questions

What was the most recent date that you arrived in Australia?

Which Visa Type/ Subclass Number did you arrive in Australia on?

What is your current Visa Type/ Subclass Number?

What date does your Visa expire?

Do you need any help with your Visa?

Are you working?

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

Where does your income come from?

Income per week after tax

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

Client's current relationship status with other party

Date cohabitation commenced

Date relationship commenced

Date of marriage

Date of separation

Date of Divorce order

Date divorce order becomes final

Was the client advised of any limitation dates

If the client has not been advised of any limitation dates, or some and not others, please explain why

Date the client was advised of the limitation

What is the primary relevant limitation date?

Please select this box where there is not yet a specific trigger date but you are still giving the advice

What is the limitation?

Please make any further notes about limitation dates here, including any further applicable limitations and their relevant dates

If you have nothing further to add, please write NA

Has the client had FVIVOs in the past? If so, provide details

If there have been no previous IVOs, please write NA

Is there a current Family Violence Intervention Order?

Date of the most recent IVO/FVSN

Is the IVO an Interim Order or Final Order?

When does the current IVO expire?

Are there current or previous Family Law Act Orders?

What is the date that the most recent Family Law Act Orders were made?

Is there a current or previous parenting plan?

What is the date of the most recent parenting plan?

Are there any previous or current Children's Court Orders in relation to one or more of these children?

Date of the most recent Children's Court Order

What was the most recent Order made in the Children's Court?

What date does/did the Children's Court order expire?

Family violence indicator

Homelessness status

Financial Disadvantage Indicator

Client consents to referral to WLSV social work

Client consents to referral to WLSV financial counselling

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.

Client consents to their matter being used as a deidentified case study for education, training, policy and law reform purposes?

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

Service Type

Primary law type

Duty lawyer service

Family Violence Legal Issues

Family Law Legal Issues

Child Protection Legal Issues

Victims Legal Service Legal Issues

Migration Legal Issues

Outreach location

Mode of service delivery

Is the client likely to be eligible for VLA funding?

If the answer to this question is yes, or unsure, please complete ALL other questions below as this information is needed to complete a VLA application for funding. The questions are not compulsory because not all clients will be assessed for, or eligible for, VLA funding at this stage.

Additional Details

Have you used any other names with Victoria Legal Aid?

What is your Centrelink Reference Number (CRN)?

Are you in custody or detention?

Custody/Detention Location

Date remanded into custody or detention

Corrective Services ID

Next are a set of questions about the client's current partner.

Do you have a Partner?

If the partner is a known perpetrator of, or alleged to have perpetrated family violence, you can select no to this question

Are they on a benefit?

What type of benefit do they receive?

Is Centrelink their only source of income?

Do you or your partner pay child support/maintenance?

How many children/maintenance dependants is the payment for?

Next are a set of questions about income, expenses and assets. if the client does not know the income details before tax, please ensure that the income Tax field = $0

Applicant Pensions/Benefits/Allowances

Please write the amount received (before tax) and the frequency

Applicant Income - Employment

Please write the amount received (before tax) and the frequency

Applicant Business/Self-Employed

Please write the amount received (before tax) and the frequency

Applicant Child Support Income

Please write the amount received (before tax) and the frequency

Applicant Other Income

Please write the amount received (before tax) and the frequency

Applicant Income Tax

Please write the amount paid and the frequency

Applicant Rent

Please write the amount paid and the frequency

Applicant Mortgage Payments

Please write the amount paid and the frequency

Applicant Board

Please write the amount paid and the frequency

Applicant Rates

Please write the amount paid and the frequency

Applicant Child Care

Please write the amount paid and the frequency

Applicant Child Support Payments

Please write the amount paid and the frequency

Partner Pensions/Benefits/Allowances

Please write the amount received (before tax) and the frequency

Partner Income - Employment

Please write the amount received (before tax) and the frequency

Partner Business/Self-Employed

Please write the amount received (before tax) and the frequency

Partner Child Support Income

Please write the amount received (before tax) and the frequency

Partner Other Income

Please write the amount received (before tax) and the frequency

Partner Income Tax

Please write the amount paid and the frequency

Partner Rent

Please write the amount paid and the frequency

Partner Mortgage Payments

Please write the amount paid and the frequency

Partner Board

Please write the amount paid and the frequency

Partner Rates

Please write the amount paid and the frequency

Partner Child Care

Please write the amount paid and the frequency

Partner Child Support Payments

Please write the amount paid and the frequency

Applicant Home Value

Applicant Home Mortgage owing

Applicant Other Real Estate Value

Applicant Other Mortgage owing

Applicant Farm/Business Value

Applicant Farm/Business Mortgage owing

Applicant Motor Vehicle Value

Applicant Motor Vehicle Loan owing

Applicant Savings

Applicant Other Assets Value

Partner Home Value

Partner Home Mortgage owing

Partner Other Real Estate Value

Partner Other Mortgage owing

Partner Farm/Business Value

Partner Farm/Business Mortgage owing

Partner Motor Vehicle Value

Partner Motor Vehicle Loan owing

Partner Savings

Partner Other Assets Value

Are you or your partner any of the following?

This is in relation to businesses/trusts etc

If yes to the previous question, please provide details

Are you currently precluded from receiving a Centrelink Benefit due to receipt of a Lump Sum?

This generally refers to lump sums above $2,000 received in the last two months, subject to what the payment was for and an explanation about why it shouldn't be used to pay for legal fees

How much did you receive?

Details of lump sum payments recieved including dates, amounts and why it can't be used to pay for legal fees

The next set of questions relates to influencing factors for this application

Are any of the follwowing influencing factors relevant to your client’s legal matter?

What Influencing Factors are associated with this application?

Influencing Factors Additional Notes

The next set of questions relates to any VLA (CP specific) referrals received to assist this client

Was the applicant given a referral to the lawyer by VLA?

Please enter the referral number provided on the referral

Reasons for absence of referral number

Please explain reasons for the absence of referral number where reasons different from options in previous question?

The next question relates to restrained property

Do you have any restrained property?

Copies of any restrains need to be submitted via ATLAS after the application has been submitted

Please advise how your client is supporting themselves if your client has indicated that they (and/or their Partner) are not receiving any income and/or they are not paying any expenses OR their expenses exceed their income.

The next set of questions form the applicant declaration on the grant application

Have you or any other person paid any of your legal fees for this case?

Name of the person who paid the legal fees

Amount of legal fees paid

Please provide further details of previous legal costs paid and why you, the person who paid or any other person is not able to continue to pay for your legal costs

Do you want this application to be assigned to another law firm?

Applicant Declaration - *READ TO CLIENT. IF THE CLIENT AGREES ASK FOR THEIR PERMISSION TO SIGN THE APPLICATION ELECTRONICALLY ON THEIR BEHALF. PLEASE ALSO COMPLETE THE 'SPECIAL ARRANGEMENTS FOR SIGNING OF THE APPLICANT DECLARATION FORM' DOCUMENT IN THE WIKI FILES. I, (i) acknowledge that it is an offence to: fail to disclose information required of me and which I know to be relevant to this application for legal assistance provide false information to VLA directly or via my legal practitioner in connection with this application for legal assistance make a false statement either orally or in writing in relation to this application for legal assistance (ii) have received a copy of VLA's Privacy Statement (iii) consent to the submission of the application for legal assistance by electronic means to VLA via the ATLAS Grants Management System available to practitioners. I declare that all the information I have given is true and correct.

Date client authorised electronic signing of application