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 the applicant wants to provide a contact person (other than you), what is their First Name?
If they have named a contact person, what is their Last Name?
Applicant Phone Number
* Required: If they don’t have, please write none.
If they have named a contact person, what is their phone number?
Applicant Email Address
If they have named a contact person, what is their email address?
* Required: Date of Birth
Applicant’s gender
Please selectMaleFemaleNon-binaryNot specifiedOtherPrefer not to say
Do they 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 they homeless or at serious risk of homelessness?
UnknownYesNoAt risk of
Are they currently in custody or detention?
UnknownYesNo
Have they experienced family violence?
Do they identify as Aboriginal or Torres Strait Islander?
Do they maintain cultural or language from outside Australia?
What is the main language they 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 them to understand? (Leave blank if “no”)
If they would like an interpreter, please say which language?
How well do they speak English?
Not stated/inadequately describedVery wellWellNot wellNot at all
How well do they read or write (in English)?
Do they have a disability or serious physical or mental health condition?
Do they currently receive Centrelink payments?
Unknown / Not disclosedYesNo
Are they currently in paid employment?
UnknownEmployedUnemployedOther
