/ CHILDREN’S COURT
FAMILY DIVISION
Private Practitioner Duty Lawyer Record / CLIENT ID
DLR ID
FILE ID –LIT / MW
Child client / No Yes

Next action Create file______Lodge Application

Other ______No further action / file away

Client first name

/ Family name
Client DOB

Client is

/ Adult/ParentChildYouthOther______

Matter of

Service details

Practitioner / Date / Time
Referred from / Court ref no
Court / Tribunal / Children’s Court – Family Division / Location

Work typeInformation only Procedural advice only Legal advice

Mention Mention (Submissions) Directions Hearing IAO Contest

IAO Adjournment IAO Appearance Conference (specify)______

Judge / Magistrate______

Matters

Matter type
(List primary matter first) / Non-appearance outcome
Information only
Procedural advice only
Legal advice
Appearance - specify outcome / Fact sheet number / Adjourned date / Other legal or non legal services referred to / Referral reason

Other appearances

Lawyer / barrister / Appearing for / Name
DHHS
M F Ch Oth ______
M F Ch Oth ______
M F Ch Oth ______

NOTE: If an Application for Aid has been completed, the Client details section on page 2 is NOT required

Client details (Please complete all questions)

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1. Personal details

Title Mr Mrs Ms Miss Mstr None

First name______

Middle name______

Surname______

Have you used any other names? Yes No

If YES, please state other names:______

______

Gender Male Female

X (indeterminate/intersex/unspecified)

Date of birth_____/_____/_____If estimate, tick

2. Contact details

Are you homeless? Yes No

Where do you live?

______

______Postcode______

Is this where you usually live? Yes No

Can we send mail to this address? Yes No

If no, where can we write to you?

______

______Postcode______

Do you prefer to be contacted by email? Yes No

Email address______

Phone numbers: Is SMS contact ok? Yes No

Mobile______Home______

Work______Other______

3. Origin

Country of birth ______Year of arrival ____

Are you of Aboriginal or Torres Strait Islander origin?

No AboriginalTorres Strait Islander

Aboriginal and Torres Strait Islander

4. Language

Do you speak a language other than English at home?

No

YesWhich language?______

Do you need an interpreter?No

YesWhich language?______

How well do you speak English?

Very well Well Not well Not at all

How well do you read English?

Very well Well Not well Not at all

5. Disability

Do you have a disability?

No Not stated(Go to Question 6)

YesWhat kind of disability?

Acquired brain injuryIntellectual Hearing

Mental health Psychiatric Physical

Speech Visual

Not disclosed Other

6. Employment status

What is your employment status?

Not employed (Go to Question 7)

Full time Part time Casual Self employed

What work do you do?______

How much do you earn each week after tax? $______

Do you support someone financially? Yes No

Does anyone support you financially? Yes No

7. Benefit details

Do you have a health care card? Yes No

Are you on a benefit? No (Go to Question 8)

YesCRN (optional)

What type of benefit do you receive?

ABSTUDY Age pension Austudy

Carer’s benefit Disability support pension

Newstart allowance Parenting payment

Partner allowance Sickness allowance

Special benefit Veterans/war service

Widow allowance Widow B pension

Wife pension Youth allowance Other

Do you receive the maximum rate of benefit?

Yes No

8. Living arrangements

What are your usual living arrangements?

What are your usual living arrangements?

Single Married Living with partner

Separated from partner Married but separated

Divorced Widowed Not applicable

Custody details: VLA use only

Custody/detention location______

______

Prison CRN ______

Date remanded into custody or detention.___/___/___

Expected release date_____/_____/_____

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Has anyone helped you to fill in this form? Yes No

Initial DHHS position______

______

______

______

Other parties’ positions______

______

______

______

______

Client’s instructions______

______

______

______

Advice to client______

______

______

Resolved by negotiation / submissions?______

______

______

Finalised or adjourned______

______

______

Actual outcome______

______

______

______

______

Comments______

______

______

______

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