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CHILDREN’S COURT
FAMILY DIVISION
CLIENT ID
Private Practitioner
Duty Lawyer Record
FILE ID – LIT / MW
DLR ID
Child client
Create file ______________________________
Yes
Lodge Application
Other _____________________________________________
Client first name
No
No further action / file away
Family name
Client DOB
Client is
Adult/Parent
Child
Youth
Other ______________________________________
Matter of
Service details
Practitioner
Date / Time
Referred from
Court ref no
Children’s Court – Family Division
Court / Tribunal
Work type
Location
Information only
Procedural advice only
Legal advice
Mention
Mention (Submissions)
Directions Hearing
IAO Adjournment
IAO Appearance
Conference (specify)
Judge / Magistrate
IAO Contest
_____________________________
_________________________________
Matters
Matter type
(List primary matter
first)
Non-appearance outcome
Information only
Procedural advice only
Legal advice
Appearance - specify outcome
Fact
sheet
number
Adjourned
date
Other legal
or non legal
services
referred to
Referral
reason
Other appearances
Lawyer / barrister
Appearing for
Name
DHHS
M
F
Ch
Oth ___________
M
F
Ch
Oth ___________
M
F
Ch
Oth ___________
NOTE: If an Application for Aid has been completed, the Client details section on page 2 is NOT required
26102015
Duty Lawyer Record – Children’s Court Family – Private Practitioner
Page 1
Client details
(Please complete all questions)
1. Personal details
Title
Mr
Mrs
5. Disability
Ms
Miss
Mstr
None
First name
__________________________________
Middle name
__________________________________
Surname
__________________________________
Have you used any other names?
Yes
No
If YES, please state other names: __________________
______________________________________________
Gender
Male
Female
X (indeterminate/intersex/unspecified)
Do you have a disability?
No
Not stated (Go to Question 6)
Yes
What kind of disability?
Acquired brain injury
Intellectual
Hearing
Mental health
Psychiatric
Physical
Speech
Visual
Not disclosed
Other
6. Employment status
What is your employment status?
Not employed (Go to Question 7)
Full time
Date of birth _____/_____/_____
If estimate, tick
Part time
Casual
Self employed
What work do you do? __________________________
2. Contact details
How much do you earn each week after tax? $ _______
Do you support someone financially?
Yes
No
Where do you live?
Does anyone support you financially?
Yes
No
______________________________________________
7. Benefit details
___________________________
Do you have a health care card?
Yes
No
Are you homeless?
Yes
No
Postcode _________
Is this where you usually live?
Yes
No
Can we send mail to this address?
Yes
No
If no, where can we write to you?
Are you on a benefit?
Yes
No (Go to Question 8)
CRN (optional)
What type of benefit do you receive?
______________________________________________
ABSTUDY
Age pension
___________________________
Carer’s benefit
Disability support pension
Newstart allowance
Parenting payment
Partner allowance
Sickness allowance
Postcode _________
Do you prefer to be contacted by email?
Yes
No
Email address __________________________________
Phone numbers: Is SMS contact ok?
Yes
No
Austudy
Special benefit
Veterans/war service
Mobile
_____________ Home ___________________
Widow allowance
Widow B pension
Work
_____________ Other ___________________
Wife pension
Youth allowance
3. Origin
Do you receive the maximum rate of benefit?
Country of birth ________________ Year of arrival ____
Are you of Aboriginal or Torres Strait Islander origin?
No
Other
Aboriginal
Yes
No
8. Living arrangements
What are your usual living arrangements?
Torres Strait Islander
What are your usual living arrangements?
Aboriginal and Torres Strait Islander
4. Language
Single
Do you speak a language other than English at home?
Separated from partner
Married but separated
Divorced
Not applicable
No
Yes
Which language? ______________________
Do you need an interpreter?
Yes
No
How well do you speak English?
Well
Custody details: VLA use only
____________________________________________
Prison CRN __________________________________
Not well
Not at all
How well do you read English?
Very well
Well
Not well
Has anyone helped you to fill in this form?
Victoria Legal Aid
Widowed
Living with partner
Custody/detention location ____________________
Which language? ______________________
Very well
Married
Date remanded into custody or detention
. ___/___/___
Expected release date _____/_____/_____
Not at all
Yes
No
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Initial DHHS position ___________________________________________________________________________
____________________________________________________________________________________________
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Other parties’ positions _________________________________________________________________________
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Client’s instructions ____________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Advice to client ________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Resolved by negotiation / submissions? ____________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Finalised or adjourned __________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Actual outcome _______________________________________________________________________________
____________________________________________________________________________________________
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Comments ___________________________________________________________________________________
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Victoria Legal Aid
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Victoria Legal Aid
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