External Referral Online Form - Gold Coast Community Legal Centre

Please complete the form below to refer a client to the Gold Coast Community Legal Centre for legal or social work assistance.

Referral from (organisation):*
Contact name/case worker:*
Phone number of case worker:*
Email of case worker:*
What type of assistance does the client require?*
Client Name:*
First Last
Client Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Client Date of Birth:*
Client Email:
Client Phone:*
Name of the other party:*
ie. the person or organisation the client is having issues with
Please describe the type of issue or situation you are seeking assistance with:*
Are there any upcoming court dates for this matter?*
Select the next court date:
Is it safe to call you at the phone number indicated?*
- Yes
- No
Is it safe to text you at the phone number indicated?*
- Yes
- No
Is it safe for our centre to leave you a voice message on this number if we cannot get hold of you?*
- Yes
- No
Do you give consent for us to contact the person who is making this referral for you if we cannot get hold of you?*
- Yes
- No
Please identify any safety issues which we need to be aware of if we try and contact you:
For example, not to identify who we are or where we are calling from, things we need to be aware of for your safety, etc.
Please indicate any specific information you want us to be aware of in our attempt to contact you:
For example, only call during certain hours.
Consent*
I agree.
I consent to this referral to the Gold Coast Community Legal Centre taking place and consent to the Centre contacting me directly to discuss how the Centre may be able to help me, taking into account any safety information identified above.