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

Referral Form

Client Referral Form

Please enable JavaScript in your browser to complete this form.

From (Referring Agency / Referrers Name) *

Referring Agency / Referrer 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

Name *

First

Last

Previous (changed) Name

Date of Birth *

Country of Birth *

Gender: (Please tick the relevant box) *

Female
Male
Other

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Other (alternative) Phone Number *

Email *

Ethnicity *

Aboriginal
Torres Strait Islander
Aboriginal & Torres Strait Islander
Culturally And Linguistically Diverse
Other

Main Language *

English
Other

Please specify language if other than English

Interpreter Required *

No
Yes

Employment Status *

Employed
Unemployed
Other

Income Source *

Earned
No income
Centrelink
Other

If receiving Centrelink, what type of payment?

Income Amount *

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

Disability Status *

Yes
No

If yes, please specify disability

Wills eligability check *

Have you been referred to PCLS by Karlka?

A brief description of the assistance or service required (Reason for referral): *

Other party: Name, Date of Birth, and Contact Details *

Please provide these details for ANY other person/s involved in this matter

party: Amount Service

Relationship to the other party? *

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

Previous (changed) Name

Date of Birth

Country of Birth

Address

Phone Number

Other (alternative) Phone Number

Email

Ethnicity

Aboriginal Aboriginal & Torres Strait Islander Torres Strait Islander Culturally and Linguistically Diverse Other

Interpreter Required

Yes No

Annual salary

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

Employment Status

Employed Unemployed Other

Income Source

Earned No income Centrelink

Does the client have any Disabilities?

Yes No

Wills Eligibility Check

Have you been referred to PCLS by Kalka? Do you receive Centrelink payments?

A brief description of the assistance or service required (reason for referral)

Child/ren names and Date/s of birth

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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