Victims Legal Services Referral

Enquiry date

Which Victims Legal Service Provider do you work for, if any?

If you do not work for a Victims Legal Service provider, which organisation do you work for?

What does the client need legal help with? (internal question)

Please hold down the 'ctrl' button to select more than one option

The client's first name

The client's last name

The client's date of birth

The first name of the other person who is involved in the legal issue

The last name of the other person who is involved in the legal issue

The date of birth of the other person involved in the legal issue

Please provide the first name, last name, date of birth and information about your relationship to the person, for any other people involved in your legal issue. If there is noone else involved in your legal issue, please say "not applicable". PLEASE LIST ALL CHILDREN HERE.

This may include children, other family members or people who are not related to your client

Conflict check complete?

Conflict identified - unable to assist

Where a conflict is identified, please select this box and then submit the form. No further details are to be completed.

No conflict identified

Where the is no conflict, please select this box and continue filling out the rest of the form

Unable to identify conflict

This box is for non-lawyers who cannot determine whether or not there is a conflict. Where you are unable to identify a conflict, please select this box and then submit the form. No further details are to be completed.

The residential street address for the client

The suburb the client lives in

The state/territory the client lives in

The postcode for the suburb the client lives in

The client's phone number

The client's email address

Does the client consent to you sharing their details/information to us to allow Women's Legal Service Victoria to

Please hold down the 'ctrl' button to select more than one option - full consent will require both options to be selected

Does this matter require urgent legal assistance?

If yes, why?

Location of event/incident

Which of these factors are relevant to the client

Please hold down the 'ctrl' button to select more than one option

If the client requires an interpreter, please select the language/dialect the client needs the interpreter for

Please enter the language the client prefers to communicate in here if it is not in the list above

How would the client like us to communicate with them?

Please hold down the 'ctrl' button to select more than one option

When is it safe to contact the client?

Please let us know of any accessibility requirements for the client

How did the client hear about the Victims Legal Service?

What details can you provide about the matter, including any Court or filing dates

Victims Legal Services Referral

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