Referral Form

Client Referral Form

Name
Gender: (Please tick the relevant box)
Address
Is the client aware of referral and agreeable to it?
Ethnicity
Main Language
Interpreter Required
Employment Status
Income Source
Income Amount
Disability Status
Have you been referred to PCLS by Karlka?
Service required: (Please tick the relevant boxes)
Please provide these details for ANY other person/s involved in this matter

To support our work, we’d like to store your personal details in our secure internal database. Your information will be protected in accordance with our data privacy standards and only accessed by authorised staff to manage your matter, provide services, maintain records and meet legal and reporting obligations.

Could you please confirm if you’re happy for us to proceed?

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.  

Close

Leave this site safely

You can quickly leave this website by clicking “EXIT” in the top right. To browse this site safely, be sure to regularly clear your browser history.

Got it