GCCLC - Client Details Form - Gold Coast Community Legal Centre

Given Names:*

Last Name:*

Other Names:

Date Of Birth: (dd/mm/yyyy)*

Phone*

Email*

Address:*

Suburb:*

Post Code:*

Gender*

Do you identify as*

Country of birth*

Main Language Spoken:*

Proficiency in English WRITTEN:*

Proficiency in English SPOKEN:*

Interpreter Required:*

Employment Status:*

Centerlink Status:*

Income Source:*

Income Scale (Weekly):*

Relationship Status:*

Number of Dependents (Children)*

Number of Dependents (Others)*

Do you have a disability impairment?*

If your answer is YES, please select*

Specify your disability impairment if your answer is 'Other'*

Are you experiencing Domestic or Family Violence?*

Are you experiencing Financial Hardship / Disadvantage?*

Are you experiencing homelessness?*

How did you hear about our Centre? Who referred you to us?*

If "Other", please specify:

Is it safe to contact you on the details you have provided?*

If "No", please tick all that apply

Do not call
Do not SMS
Do not mail
Do not E-mail

If "No", please tick all that apply.

Do not call
Do not SMS
Do not mail
Do not E-mail
Other

Do you consent to a de-identified case study should the Centre be able to assist you in achieving a successful outcome?*

NOTE: Case studies are a summary of a matter where the Centre assisted in achieving a successful outcome. Case studies do not contain any identifying facts or particulars about you - they provide a summary of the legal issue and how the Centre assisted. If you would like more information about what a case study is, please discuss with our reception or the solicitor.

Full name of the other person or business you have an issue with*

Other Party's date of birth (if known)

CLIENT ACKNOWLEDGEMENT AND DISCLAIMER:

Please read the following information carefully before signing. If you have any questions, our staff are happy to explain any part of this form.

1. I confirm that I have received a copy of Gold Coast Community Legal Centre’s Client Information brochure.

2. I understand that the legal advice and/or social work support I receive depends on the accuracy and completeness of the information and documents I provide to the Centre.

3. I understand that the Centre provides legal advice and/or social work support on a limited basis and that, unless I enter into a separate written client agreement with the Centre:

the Centre is not acting as my ongoing lawyer;
social work support is short-term and non-ongoing;
there is no continuing professional retainer; and
the professional relationship ends at the conclusion of my appointment.

4. I understand that further assistance after my initial appointment may be limited or declined depending on:

the complexity of my matter;
demand for services at the Centre; and
my level of vulnerability or disadvantage.

5. I understand that the Centre keeps my information confidential and will only disclose it if:

I give permission; or
the law requires it (for example, to prevent imminent and serious harm).

6. I understand that the Centre collects personal information in order to provide legal and social work services and complies with its Privacy Policy when handling my information. The Centre uses secure online systems and digital technologies to collect, store, process and manage client information. The Centre may also use technology tools, including AI-assisted systems where appropriate to support its services and administrative functions. Any use of AI in connection with my matter will be discussed with me in advance and, where required, my consent will be obtained. A copy of the Privacy Policy is available on request.

7. I understand that if I choose to have a support person present during my appointment, that person is not bound by legal professional privilege or the Centre’s confidentiality obligations, as they are not the client.

8. I understand that solicitors and social workers at the Centre operate under different professional obligations and guidelines. I may ask staff for clarification if I would like more information about these differences.

9. I understand that the Centre stores my file and documents securely for seven (7) years after providing assistance. I give permission for the Centre to destroy these records after that period.

10. I understand that if I am a new client who has not previously used the Centre, the Centre will retain this intake form and the information I provide for one month.

If I do not attend the Centre within that time, my personal details will be removed from the system.
If I request assistance after that time, I will need to complete a new intake form.

CLIENT DECLARATION:

I confirm that I have read and understood the information above. I agree to the terms outlined in this Client Acknowledgement and Disclaimer.

Client Signature (type your full name)*

Date:*

Please complete this Client Details Form below. The information you submit to us will always remain confidential.

CLIENT ACKNOWLEDGEMENT AND DISCLAIMER:

CLIENT DECLARATION: