Please complete the form below and we will be in contact as soon as possible about your enquiry.  All questions marked * are compulsory.  All data collected will be kept private and confidential.

Have you been to Fitzroy Legal Services before? (Please select) No Yes

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

If Yes, who referred you?

Name of Person or Organisation in dispute with?

What is the legal issue(s) you are seeking advice about?

First Name

Family Name

Date of Birth

Post Code

Phone Number

When is the best time to call?

Email Address

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

Are you Aboriginal or Torres Strait Islander? Aboriginal Torres Straight Islander Neither

Are you experiencing family violence? Yes No At risk of

Are you experiencing homelessness? Yes No At risk of

Do you have a disability? 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

What is your family situation? 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? Yes No

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

Do you receive Centrelink? 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? Yes No