1Instructions2Client Details & Consent3Money Troubles4Housing Concerns5Civil Law6Family and Relationships7Health and Wellbeing8Crime9SubmitInstructionsEach section has hyperlinks in bold.Please click on the hyperlinks to get more information about that issue to help you and the person understand it more together and see if there are any problems in that areaPlease fill out as much information as you can. We will still accept any referral even if you can’t answer all the questions on the form. This is a tool to help you and the person you are referringInstructions - enter here or upload a fileUpload InstructionsMax. file size: 256 MB.Client DetailsFull NameDate of birth (dd/mm/yyyy)Gender M F OWhere do your live? Street Address Address Line 2 City State Postcode Do you have a different Postal address? NO YESPostal Address Street Address Address Line 2 City State Postcode What is the best way to contact you? Phone Email Family member OtherPhone number:Email: Enter Email Confirm Email Family member name:Family member phone or email:Other, please specify:Which health and other support services are helping you now?Income: Aboriginal Torres Strait IslanderDo we both need an interpreter to understand each other? Yes NoLanguage:Service Provider Information and CONSENTService Provider Full NameService Provider Email* Enter Email Confirm Email OrganisationContactI confirm that I have explained this form to the the person named here and they understood and gave permission for their information to be given to the Northern Territory Legal Aid Commission. The person understands that Northern Territory Legal Aid Commission will contact them to make an appointment and no work will be done on the problem until they have spoken to the service.Signed - enter your full nameDate DD slash MM slash YYYY Money Troubles (Debt)Is anyone chasing you for money?Is anyone chasing you for money? Yes No Not sureDo you have any bills that you cannot pay?Do you have any bills that you cannot pay? Yes No Not sureHiddenDo you need to get your superannuation or a family member's superannuation?Do you need to get your superannuation or a family member's superannuation? Yes No Not sureDo you want to apply for any compensation?Do you want to apply for any compensation? Yes No Not sureAre you getting the right money from Centrelink?Are you getting the right money from Centrelink? Yes No Not sureDo you have any fines that you have not paid?Do you have any fines that you have not paid? Yes No Not sureEnter the money you owe details here (optional):Who you owe money toHow much you owe them? (roughly)How much $ you need to pay every week / fortnight or month? Please describe the issues in a sentence or two.Housing WorriesDo you owe any rent?Do you owe any rent? Yes No Not sureAre you having trouble getting the landlord to do repairs or maintenance?Are you having trouble getting the landlord to do repairs or maintenance? Yes No Not sureHave you recently been evicted (this means told you have to move out of your house)?Have you recently been evicted (this means told you have to move out of your house)? Yes No Not sureDid you get your bond money back?Did you get your bond money back? Yes No Not sureIf you moved out, did you leave any belongings in your house that you want to get backIf you moved out, did you leave any belongings in your house that you want to get back Yes No Not surePlease describe the issues in a sentence or two.Civil LawDid you get hurt in an accident?Did you get hurt in an accident? Yes No Not sureDo you have any problems with your boss?Do you have any problems with your boss? Yes No Not sureDid someone at work or in the community treat you unfairly?Did someone at work or in the community treat you unfairly? Yes No Not surePlease describe the issues in a sentence or two.Family and RelationshipsDo you want help with domestic violence orders?Do you want help with domestic violence orders? Yes No Not sureDo you want help with divorce/separation?Do you want help with divorce/separation? Yes No Not sureDo you want help with child protection?Do you want help with child protection? Yes No Not sureDo you want help with working out who takes care of children?Do you want help with working out who takes care of children? Yes No Not sureDo you want help with your experiences as a child when you were in the care of adults or institutions?Do you want help with your experiences as a child when you were in the care of adults or institutions? Yes No Not surePlease describe the issues in a sentence or two.Health and WellbeingDoes the adult guardian make decisions about your health or business?Does the adult guardian make decisions about your health or business? Yes No Not sureDoes a public trustee make decisions for you or a family member?Does a public trustee make decisions for you or a family member? Yes No Not sureDo you have an order from the Mental Health Tribunal?Do you have an order from the Mental Health Tribunal? Yes No Not sureDo you get any disability support money? (like a pension or NDIS – National Disability Insurance Scheme)Do you get any disability support money? (like a pension or NDIS – National Disability Insurance Scheme) Yes No Not sureDo you need a lawyer’s help with power of attorney?Do you need a lawyer’s help with power of attorney? Yes No Not surePlease describe the issues in a sentence or two.CrimeDo you have to go to court?Do you have to go to court? Yes No Not sureDo you have a warrant?Do you have a warrant? Yes No Not sureDo you want to complain about how the police or prison treated you?Do you want to complain about how the police or prison treated you? Yes No Not sureDo you want help with the Banned Drinker Register?Do you want help with the Banned Drinker Register? Yes No Not sureHave you been a victim of a crime?Have you been a victim of a crime? Yes No Not surePlease describe the issues in a sentence or two.Additional notesEmail address to send a copy of this form to the client (optional) Δ
