Enquiry Form

Please complete the form below.

Types of issues we can help with and advise on include, but are not limited to:

• Discrimination, harassment and/or violence on the basis of LGBTIQA+ identity
• Issues affecting trans and gender-diverse people, such as name change or access to services
• Family violence
• Family law
• Employment law
• Tenancy law

Please fill in this form and we'll get back to you as soon as possible.

All questions marked * are compulsory.
All data collected will be kept private and confidential.

If you have a support person they can help you fill out this form, or contact our Intake Officer on 03 9968 1002 for assistance.

Have you received assistance from Fitzroy Legal Service before? (Please select) No Yes

Were you referred to Fitzroy Legal Service by someone or an organisation? (Please select) No Yes

If Yes, who referred you?

Fitzroy Legal Service runs a clinic committed to providing safe and inclusive legal services to the LGBTQIA+ community. This clinic is open to all community members regardless of your legal issue.
Would you like an appointment with the LGBTQIA+ Clinic? (Please select) No Yes

First Name

Family Name

Date of Birth

What is your gender? (Please select) Cis woman Cis man Transwoman Transfeminine Sistergirl Transman Transmasculine Brotherboy Non-binary Genderqueer Genderfluid Gender non-conforming Gender questioning Pangender Agender Other Prefer not to say

What are your pronouns? (You can select more than one) (Please select) She/her He/him They/them Other

For further information on pronouns, please see: https://www.minus18.org.au/articles/what-are-pronouns-and-why-are-they-important

Address

Suburb

Post Code

Phone Number

Details: When is the best time to contact you?

Email Address

What kind of legal problem are you seeking help for? Please select Animal law Criminal law Family law Intervention order Civil law Employment law Tenancy law Other

Name of Person or Organisation in dispute with?

What is the legal issue(s) you are seeking advice about? (Please provide as much detail as you can in a few lines)

Are you Aboriginal and/or Torres Strait Islander? (Please select) Aboriginal Torres Strait Islander Both Neither

Are you experiencing family violence? (Please select) Yes No At risk of

Are you experiencing homelessness? (Please select) Yes At risk of No

Are you living with a disability? (Please select) Yes No

If yes, what type of disability? N/A Sensory- Speech Sensory- Hearing Sensory- Visual Intellectual Physical Psychological Head injury/Stroke/Brain injury ABI Autism Developmental Delay Neurological Blood borne Undisclosed Other

Do you have any support needs?

What is your family situation? (Please select) Never Married/Single Married/DeFacto Separated Divorced Widowed Unknown (Not Stated/Not adequately described)

Do you have dependent children living at home? No Yes

Are you working at the moment? (Please select) Yes No

About how much do you earn each week? (Please select) No Income $1 - $599 $600 - $1249 $1250 or more

Do you receive a Centrelink benefit? (Please select) Yes No

If yes, what type of payment? NA Newstart Youth Allowance DSP Age Pension ABSTUDY Veterans Benefit Parenting Payment Carers Payment AUSTUDY Job Keeper Job Seeker Family Tax Benefit Other

What is the main language you speak?

Do you need an interpreter? (Please select) No Yes