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Queensland Public Interest Law Clearing House Incorporated Self-Representation Civil Law Service (SRCLS)Client Intake FormBefore completing this form, please read: SRCLS Information Brochure for information on the eligibility guidelines used for assessing who can be assisted by the SRCLS; and  QPILCH’s Privacy Policy describing how QPILCH manages your personal information and safeguards your privacy.If this form contains privileged or confidential information, or both, it is solely for the use of QPILCH and it remains solely the property of QPILCH.You must complete all sections of this form. Incomplete or partially completed forms will not be assessed by the SRCLS.Please return this form, together will all relevant documents, to:Solicitor Self-Representation Civil Law Service Queensland Public Interest Law Clearing House In person: Law Courts Complex, 304 George Street Brisbane Qld 4000 Postal Address: GPO Box 1543 Brisbane Qld 4001 Fax: 07 3012 9774 Email: [email protected] 1. Client detailsDate______Date of birth______Client type  Individual  Organisation  CompanyName (of individual, organisation or company)______Address______State______Postcode______Telephone______Mobile______Fax______Email______Organisations Contact person______Position in organisation______Number of members______Gender  Male  FemaleCountry of birth______GPO Box 1543 Brisbane Qld 4001 t: 07 3012 9773 f: 07 3012 9774 e: [email protected] 1 Are you an Australian citizen?  Yes  NoIs English your first language?  Yes  No (please specify)______What is the main language spoken at your home?______Proficiency in (spoken) English  Very well  Well  Not well  Not at allDo you require an interpreter?  Yes (which language?)______ NoIndigenous status  Aboriginal  TSI Origin  Both  NeitherDo you have a disability?  Yes (please provide details if you need assistance)______ NoFamily / marital status  single  married  2 parent family with dependent children  de facto  not living in a family (eg, boarder, share  separated house, alone, boarding house, hostel)  divorced  sole parent with dependent children  widowed  other (please specify) ______Referral source  Bar Association of Queensland  Local, State or Federal Government  Community legal centre Department, Agency or Authority (please  Community support service specify) ______ Court Information Network  Judge  Dispute resolution service  Queensland Courts staff (eg, Judge’s  Family, friend or colleague Associate, Bailiff, Lists Clerk)  Law firm  Other State or Federal Court or Tribunal  Legal Aid Queensland  Supreme and District Courts Registry  Queensland Law Society  Other (please specify)  Private legal practitioner ______2. Financial informationIndividuals Income source  Full time employment  Casual employment  Part time employment  Self employed  Centrelink (please specify type of benefit) ______ Other (eg, rent, interest, dividends, workers compensation, superannuation) ______Client Intake Form QPILCH Self-Representation Civil Law Service 2 ______What is your annual gross income?  $0 - $20,000  $20,001 – $40,000  $60,001 - $80,000  $40,001 - $60,000  $80,000+What is the value of your assets? ______What is your fortnightly income? ______What is your fortnightly expenditure? ______Organisations What is the source of your funding?______Is there a written funding agreement? (If so, please provide to the SRCLS)______3. Existing / previous legal adviceLegal Aid  Application lodged  Application refused  Grant ceiling exceeded  Application granted  Refusal being appealed  Not applied forDo you have existing relationships with other legal advisers or representatives? If yes, please provide adviser’s name and organisation and details of why they cannot assist you further.  Yes  No__________________Please provide details of any previous advice / assistance you have received in relation to your legal problem or court proceedings, including the adviser’s name and organisation. __________________4. Current court proceedings (if applicable)Court File No.______Court Name______Registry______Which party are you?  Plaintiff  Defendant  Applicant  RespondentPlease list the names and details of the party or parties. Relationship to Role Name Legal Representative you (if applicable)Client Intake Form QPILCH Self-Representation Civil Law Service 3  Plaintiff Defendant Applicant RespondentPlease list the names of any other parties involved (or potentially involved) in your court proceedings. __________________Please list the steps that have been taken by you or the other party or parties and the date they were taken in relation to your court proceedings.Step Taken by DatePlease list the next step or steps that needs to be taken by you or the other party or parties and the date that they are due in relation to your court proceedings.Step To be taken by Due date5. Your legal problemPlease list any limitation dates that exist in relation to your legal problem or court proceedings.______Client Intake Form QPILCH Self-Representation Civil Law Service 4 ______Please briefly describe your legal problem or court proceedings. (please attach more paper if necessary)__________________________________________________________________What area of law does your legal problem or court proceedings involve?  Commercial or Tax  Government pensions benefits allowances  Consumer complaints  Immigration  Constitutional  Injuries (assault, employment, transport)  Contracts  Motor vehicle  Corporations  Neighbourhood disputes  Civil violence / restraining orders  Planning and Environment  Credit, debt or bankruptcy  Property  Defamation  Tenancy  Discrimination  Wills / Probate  Employment  Other (please specify)  Government / Administrative Law ______What assistance do you seek?  Advice  Referral for legal representation  Conducting legal research  Settlement  Drafting court documents  Assistance with an associated problem  Drafting correspondence  Other (please specify)  Drafting other documents ______Do you seek information regarding?  Alternative dispute resolution  Court proceedings and the judicial role  Potential orders, including costs orders  Legal concepts  Effect of not complying with orders  Rights and perspective of the other party  How to present your court proceedings in  Perspective and requirements of the court the best light and in the best possible way  Court rules and proper processClient Intake Form QPILCH Self-Representation Civil Law Service 5  Other (please specify) ______Client Intake Form QPILCH Self-Representation Civil Law Service 6 6. Acknowledgement and signatureI,______(client or authorised person) confirm that: the information contained in this form is correct; and  I have been given and have read QPILCH’s privacy policy and agree to QPILCH managing my personal information in accordance with its policies as issued from time to time.I authorise QPILCH to: assist me to collect and collate all facts and documents necessary (including sensitive information) to assess whether this matter complies with QPILCH guidelines;  request, transfer and receive personal information and documentation in relation to me for the purpose of providing assistance without waiving any legal professional privilege; and  give this information to member law firms and barristers, and other organisations for the purpose of assessing my eligibility for assistance and providing assistance.My authority continues until I withdraw it in writing.I acknowledge that QPILCH has no legal responsibility or liability to me where: my application is declined by QPILCH; or  my application is referred to a member law firm or barrister, in which case I authorise the member to report to QPILCH on the progress and outcome of the matter on a confidential basis and without waiving any legal professional or other privilege, but to enable QPILCH to monitor its referral program.Signed______Date______This form was completed by:  Client  QPILCH  Other (please specify)  Community Legal Ctr  Legal Aid ______7. Completed by QPILCH paralegalFile open date______File No.______Action Taken  Eligible for assistance  Referred  Diverted  Not eligible for assistance (please specify reason)______Conflict Check Done by______Date______Client Agreement signed  Yes  No eCourts search  Attached  Not available  Not applicableClient Intake Form QPILCH Self-Representation Civil Law Service 7

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