Warm Referrals

Warm Referral Form

Data Collection Notice - We will ask for personal details related to your client. If you do not have permission to provide this information, please instead ask your client to contact us directly via our website.
Your Name*

First NameLast Name
Your Organisation*
Your Email address*
example@example.com
Your phone number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Great Southern Community Legal Services operate a range of programs that provide targeted assistance to people in our community. Please choose which program best suits your client, or choose unsure if you would like to discuss this latter with our Client Services team.
Referral Program*

Legal Given Names*
Legal Last Name*
Preferred Name
Client's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Contact Telephone Number
If the Client can not be safely contacted on their number, please do not fill it in here.
Telephone Safety Checks

Safe to TelephoneSafe to SMSSafe to leave VoicemailOther
Please note - It is a condition of this service type that clients have a disability or mental health condition
Client's Disability(s)
Client's Mental Health Condition(s)
Client's Date of Birth*

DayMonthYear
Client's Average Income (per fortnight)
Names and Dates of Birth of any Children

Disability Advocates work collaboratively with other agencies that are assisting the client to assist them to resolve their issues. Please list below any agnecies that you are aware of that are assisting the Client. Include best contact person if known.
List all agencies involved

We will now collect some details about other people that are involved in the matter. This includes people who may be assisting your client to resolve the matter (who we will call 'additional parties'), as well as people who are causing the problem and/or are opposed to the matter being resolved in your clients favour (who we will call 'other parties').
Additional Party - Legal Given Names
Additional Party - Legal Last Name
Date of Birth

DayMonthYear
Relationship to Client
Are there any more additional parties?*

We will now collect some details about other people that are involved in the matter. This includes people who may be assisting your client to resolve the matter (who we will call 'additional parties'), as well as people who are causing the problem and/or are opposed to the matter being resolved in your clients favour (who we will call 'other parties').
Additional Party #2

First NameLast Name
Date of Birth

DayMonthYear
Relationship to Client
Are there any more additional parties?*

We will now collect some details about other people that are involved in the matter. This includes people who may be assisting your client to resolve the matter (who we will call 'additional parties'), as well as people who are causing the problem and/or are opposed to the matter being resolved in your clients favour (who we will call 'other parties').
Additional Party #3

First NameLast Name
Date of Birth

DayMonthYear
Relationship to Client
Are there any more additional parties?*

Multiple Additional Parties

After you finish this form, please send us an email at referrals@gscls.com.au with the details of the remaining additional parties to this matter.

We will now collect some details about other people that are involved in the matter. This includes people who may be assisting your client to resolve the matter (who we will call 'additional parties'), as well as people who are causing the problem and/or are opposed to the matter being resolved in your clients favour (who we will call 'other parties').
Other Party - Legal Given Names
Other Party - Legal Last Name
Date of Birth

DayMonthYear
Are there any more additional parties?*

We will now collect some details about other people that are involved in the matter. This includes people who may be assisting your client to resolve the matter (who we will call 'additional parties'), as well as people who are causing the problem and/or are opposed to the matter being resolved in your clients favour (who we will call 'other parties').
Other Party #2

First NameLast Name
Date of Birth

DayMonthYear
Are there any more additional parties?*

We will now collect some details about other people that are involved in the matter. This includes people who may be assisting your client to resolve the matter (who we will call 'additional parties'), as well as people who are causing the problem and/or are opposed to the matter being resolved in your clients favour (who we will call 'other parties').
Other Party #3

First NameLast Name
Date of Birth

DayMonthYear
Are there any more additional parties?*

Multiple Other Parties

After you finish this form, please send us an email at referrals@gscls.com.au with the details of the remaining other parties to this matter.

Declaration

By submitting this form I declare that I have obtained consent of my Client to provide Great Souhtern Community Legal Services with their personal information, and that all information is true to the best of my knowledge.
Should be Empty:

Warm Referral Form