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Home
Services
About
Resources
Projects
- Love Shouldn’t Hurt
Support Us
- Supporters
- Donate
Referral
Contact

Client Feedback Form

Client Feedback Form

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First Name *

Last Name *

Email *

Phone Number *

Which service does this feedback relate to? (Please tick the revant box(es))

Reception
Tenancy Advocate
Financial Counselling
Legal
Housing Support
Redress Support
Domestic Violence
Migrant Services

Which office does this feedback relate to?

Karratha
Roebourne
South Hedland
Newman
Other

Please specify the date and time (if possible) that your feedback relates to:

Date

Time

Does this feedback relate to a specific employee?

Yes
No

If yes, which employee(s) does this feedback relate to?

Message

Please Note: ALL feedback will be referred to the Principal Solicitor for review

From (Referring Agency/ Referrers Name)

Phone Number

Is the client aware of referral and agreeable to it?

Yes No

Service required: (Please tick the relevant boxes)

Tenancy Advocate Financial Counselling Legal Housing Support Redress Support Domestic Violence Migrant Services

Last Name

First Name

Date of Birth

Country of Birth

Address

Phone Number

Email

Ethnicity

Aboriginal CALD Other

Annual salary

$0 - $40,000 $40,000 - $80,000 $80,000 - $100,000 $100,000+

Child/ren names and Date/s of birth

Does the client have any Disabilities?

Yes No

Supporting Information (reason for referral):

Name/s and DOB of other party/s or related party/s (ie ex-partner):

(08) 9185 5899
admin@pcls.net.au
PO Box 132
Karratha WA 6714

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Pilbara Community Legal Service is accredited with the National Legal Scheme for Community Legal Centres

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Acknowledgement of Country

Pilbara Community Legal Service recognises the traditional owners of the lands across the Pilbara region and particularly the traditional owners on which the Pilbara Community Legal Service Offices are situated. We pay deep respect to Elders both past and present.

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