MACKAY REGIONAL COMMUNITY LEGAL CENTRE (MRCLC)CONFIDENTIAL CLIENT ADVICE FORM – GENERALIST MRCLC Confidential Client Advice Form - Generalist Office Use only Client ID: Service ID: Service ID(Task): Conflict Check: ☐ Initials: Date: Personal DetailsFamily Name* First and Middle Names* Any other names used (maiden name?) Address* Postal Address (if different) Email* Home PhoneWork / Mobile PhoneDate of Birth* DD slash MM slash YYYY Client Type* Individual Couple Organisation / Group Gender* Male Female not male or female Transgender Intersex or Indeterminate Best way to contact you?* at home at work (during day) on mobile via text message via email May we leave a message?* Yes No Do you identify as Aboriginal Torres Strait Islander South Sea Islander N/A (your answer does not affect your eligibility for our service in any way) Name of any adult attending appointment with you If another person accompanies you in your appointment you may be waiving client legal privilege.Contact with MRCLCHave you had an appointment with MRCLC before? Yes No Date of Last Contact DD slash MM slash YYYY How did you hear about us? Employment StatusEmployment Status Employed Unemployed Centrelink Payment Yes No Centrelink Payment type Income scale / Money received (per week) (eg wages / pension / superannuation)NoneNegative$1 - $199$200 - $299$300 - $399$400 - $599$600 - $799$800 - $999$1000 - $1249$1250 - $1499$1500 - $1999$2000+Statistical Details(We must ask the following questions, but you do not have to answer them)Country of BirthAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweYear of ArrivalMain Language Request Interpreter? Yes Yes, non-spoken communication Interpreter Language Non-Spoken Communication type English Proficiency (Spoken) Very well Well Not well Not at all Einglish Proficiency (Written) Very well Well Not well Not at all Family Type Sole parent with dependent children 2 parent with dependent children Not living in a family Do you have a disability? Yes No Disability Type/Medical Condition Legal Matter / Type1.2.3.4.Is Family Violence an issue in this matter? Yes No At risk Unknown Not Applicable Other PartiesWhat is the full name of all of the following parties in this matterName Relationship to you Date of Birth DD slash MM slash YYYY PhoneAddress Their solicitor DisclaimerI confirm the above information is true and correct. I authorise the MRCLC to destroy this advice form and any other documents or letters, including all contents of my client file in this matter that are in the MRCLC’s possession from 7 years after (a) the date of this advice or, if applicable, (b) the end of any casework they perform in this matter. I acknowledge and consent to the MRCLC storing any part of my matter electronically or in hard copy and that MRCLC may change from one form to the other at any time. I consent to my de-identified information (that is, not using my real name) being used by the MRCLC in their reports to funding bodies, funding submissions or any other way they consider appropriate. The information I provide will not be shown to people outside of Centre staff and volunteers without my permission, unless it is required to be disclosed by law, or where it is necessary to comply with the requirements of MRCLC’s professional indemnity insurance cover and/or their national Community Legal Centre accreditation scheme requirements. I understand the MRCLC Client Charter is available at reception and on the MRCLC website. I have either a) read the Client Charter, b) had it read to me, or c) been offered the opportunity to read it or have it read to me. I confirm this is a one-off advice appointment unless a solicitor from the day service contacts me and agrees to undertake further work. I agree to the above disclaimer.* Yes Today's Date* DD slash MM slash YYYY Office Use Only Type of Service Legal Advice Legal Task Duty Lawyer Non-legal Support If a Legal Advice Phone In Person Post/Email Video Conferencing Other If a legal task(e.g. Letter to OP, Application) Type Client Communication Assist Draft document Draft letter/email Other Mode of Service Delivery Telephone In person Letter/Fax/Email Video Conference Other Estimated Time Spent Less than 15 mins 15-30 mins 30-60 mins 1-5 hours 6-20 hours Outreach Location(If applicable) Bowen Cannonvale Proserpine Sarina Moranbah Mackay(out of office) Referrals If referred to MRCLC – client is to ring and book another appointment. Simple / Facilitated referral? 1/ 2/ 3/ 4/ Financial Disadvantage Indicator Yes - not have means to pay Yes - Centrelink benefit Yes - not access finances temporarily Yes - other, see Notes No NA Unknown DETAILS OF LEGAL PROBLEM AND ADVICE: SEE ATTACHED FILE NOTE & DOCUMENTATION NOTE STOP: Must state Yes, No, N/A or Expired Limitation Date Yes No Date: Client Advised? Yes No Interpreter Used Yes No Language If Legal Advice Evenings, does the client want to see a social worker Yes No N/A Legal Aid provision Applied lodged Applied, refused Grant ceiling exceeded No Not stated Not applicable Homelessness status? Yes No At risk of Unknown Advisor's Name Signature Date Supervisor's Name Signature Date
