Please complete the form below and we will be in contact as soon as possible about your enquiry. You need to complete all questions marked with *. All data collected will be kept private and confidential

Have you received assistance from Fitzroy Legal Service before? (Please select) No Yes

Were you referred to Fitzroy Legal Service by someone or an organisation? (Please select) No Yes

If Yes, who referred you?

First Name

Family Name

Date of Birth

Address

Suburb

Post Code

Phone Number

Details: When is the best time to contact you?

Email Address

Name of Person or Organisation in dispute with?

What is the legal issue(s) you are seeking advice about? (Please provide as much detail as you can in a few lines)

Which gender do you identify with? Please select Female Male Transgender Male/Transman/FTM Transgender Female/Transwoman/MTF Gender Queer Intersex or Intermediate Transgender X not male or female Other Decline to answer

What are your preferred pronouns? N/A She/her/hers He/him/his They/them/theirs Other

Are you Aboriginal and/or Torres Strait Islander? Please select Aboriginal Torres Straight Islander Neither

Are you experiencing Family Violence? Please select Yes No At risk of

Are you experiencing homelessness? Please select Yes At risk of No

Are you living with a disability? Please select Yes No

If yes, what type of disability? N/A Sensory- Speech Sensory- Hearing Sensory- Visual Intellectual Physical Psychological Head injury/Stroke/Brain injury ABI Autism Developmental Delay Neurological Blood borne Undisclosed Other

Do you have any support needs?

What is your family situation? Please select Never Married/Single Married/DeFacto Separated Divorced Widowed Sole Parent with Dependent children Two Parent Family with Dependent Children Unknown (Not Stated/Not adequately described)

Are you working at the moment? Please select Yes No

If yes, about how much do you earn each week? Please select $1 - $199 $200 - $299 $300 - $399 $400 - $599 $600 - $799 $800 - $999 $1000 - $1249 $1250 - $1499 $1500 - $1999 $2000 or more unknown No Income

Do you receive a Centrelink benefit? Please select Yes No

If yes, what type of payment? NA Newstart Youth Allowance DSP Age Pension ABSTUDY Veterans Benefit Parenting Payment Carers Payment AUSTUDY Job Keeper Job Seeker Family Tax Benefit Other

What is the main language you speak?

Do you need an interpreter? Please select No Yes