Title of Applicant (person who needs legal help)
Mr.Mrs.Ms.Mx.Dr.MissHon.Rev.RabbiRep.Sen.MasterSirLadyAssistant ProfessorAssociate Prof.Associate ProfessorCav.Chief JudgeChief MagistrategeJudgeJusticeMagistrateMr and MrsMr & MsMrs & MrMs & MrPresidentPrincipal RegistrarProfProfessorProfessor DrRegistrarSenatorSenior ConstableSergeantThe HonThe Hon.The Hon JudgeThe Hon JusticeThe Hon. JusticeThe HonorableThe Honourable Justice
First Name of Applicant
Middle Name
Last Name of Applicant
Preferred Name (if different from above)
If you want to provide a contact person, what is their First Name?
If you want to provide a contact person, what is their Last Name?
Applicant Phone Number
* Required: If you don’t have a phone number, please write none.
If you have named a contact person, what is their phone number?
Applicant Email Address
* Required: If you don’t have an email address, please write none.
If you have named a contact person, what is their email address.
* Required: Date of Birth
Your Gender
Please selectMaleFemaleNon-binaryNot specifiedOtherPrefer not to say
Do you identify as LGBTQIA+?
Unknown / Not DisclosedYesNo
Physical Address (Number and Street)
Physical Address (Suburb)
Physical Address (State)
Physical Address (Post Code)
Mailing Address (if different from above)
Are you homeless or at serious risk of homelessness?
UnknownYesNoAt risk of
Are you currently in custody or detention?
UnknownYesNo
Have you experienced family violence?
Do you identify as Aboriginal or Torres Strait Islander?
Do you maintain culture or language from outside Australia?
What is the main language you speak at home?
Unknown / Not disclosed / not statedEnglishAboriginal / Australian Indigenous LanguageNorthern European LanguageSouthern European LanguageEastern European LanguageAsian LanguageAfrican LanguageSouth American LanguageOceania LanguageAuslan / Sign LanguageOther
Would an interpreter help you to understand? (Leave blank if “no”)
If you would like an interpreter, in what language?
How well do you speak English?
Not stated/inadequately describedVery wellWellNot wellNot at all
How well do you read or write (in English)?
Do you have a disability or serious physical or mental health condition?
Do you currently receive Centrelink payments?
Unknown / Not disclosedYesNo
Are you currently in paid employment?
UnknownEmployedUnemployedOther
How did you find out about Law Access?
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