Confidential Client Assessment Sheet Children S Matters and Agreement to Participate

CONFIDENTIAL – CLIENT ASSESSMENT SHEET CHILDREN’S MATTERS AND AGREEMENT TO PARTICIPATE

Lodged by: VM

of: Brisbane, Legal Aid Queensland

Date: 26 February 2015

THIS FORM MUST BE SENT TO THE CONFERENCE ORGANISER WITHIN 7 DAYS

We cannot organise your conference without this form.

NOTE: If there is a Domestic Violence Protection Order in place and you are the Aggrieved, please complete and return the attached Consent Form with this Client Assessment Sheet

· What we ask is to help you with your case.

· What you tell us is private, only we, your solicitor and the mediator may see it.

· If you need help to complete this form please contact your Conference Organiser.

Your Name: / File Reference:
Your conference organiser is: / Your conference organiser’s phone number:

Who are the OTHER people involved in your dispute?

Name: ……………………………………………….. / Name: …………………………………………………….

Who are the Child/ren in your dispute?

Name: ……………………………………………………………….….. / Date of Birth:………………………
Name: …………………………………………………………………... / Date of Birth: ……………………...
Name: ……………………………………………………………….….. / Date of Birth: ……………………...
Name: …………………………………………………………………... / Date of Birth: ……………………...

Please tell us:

1. Do you have any special needs? Yes No

(E.g. do you need an interpreter, cultural support or other help? Do you have a disability?)

If yes, please tell us or call your conference organiser for help:

……………

2. Do you have health problems that affect your ability to talk

about your matter? (E.g. alcohol or drug use/mental or other illness) Yes No

If yes, please give details:

3. Does the other party have health problems that may affect their

ability to talk about your matter? (E.g. alcohol or drug use/mental or other illness) Yes No

If yes, please give details:

4. Have you engaged a solicitor? Yes No

If yes, please give name of firm and contact details of solicitor.

Family Court and / or Federal Circuit Court

5. Have you been to Family Court or Federal Circuit Court (FCC)

about the child/ren? If yes, please give details: Yes No

6. Are there any current Family Court/FCC Orders? (Please send copies) Yes No

Domestic Violence

7. Tell us about the level and type of conflict/family violence between you while together?

Level: High Medium Low None

Type: Physical Verbal Emotional Financial None

8. Can you describe the level and type of conflict/family violence between you now?

Level: High Medium Low None

Type: Physical Verbal Emotional Financial None

9. Is there a current Protection Order (DVO)? (Please send a copy) Yes No

10. If yes, have there been any breaches of the Protection Order? Yes No

11. Do you have any reason to be concerned about your safety

currently? If yes, please give details: Yes No

12. Would you feel comfortable talking about your family law matters

with the other person present? Yes No

13. Do you think that the child/ren are safe with the other person? Yes No

If no, why not?

Department of Child Safety and / or Child Protection Unit

14. Are the Department of Child Safety or Child Protection Unit of the police

currently involved with your family? Yes No

If yes, please give details including area office, case officer, or police station:

15. Is there a Child Protection Order in place? (please attach a copy) Yes No

Previous Mediations

16. Have you attended any other mediation sessions? Yes No

If yes, which agency did you go to and when?

17. Did you reach any agreement at the previous mediation? (verbal or written) Yes No

Contact Details & Availability

18. Conferences are held on weekdays with start times of 9am or 1pm, and are limited to 4 hours duration. Tell us if there are days, times that you cannot attend and why. This will be one factor taken into account when scheduling a conference.

19. What is the quickest way to contact you?

Telephone/Mobile: ………………………………………………………

Email: ……………………………………………………………………

Please give any further details to any questions on the form and to tell us about your needs, your problem and current arrangements for the child/ren.

AGREEMENT TO PARTICIPATE in a family dispute resolution conference with LEGAL AID QUEENSLAND

20. Completed by Client Yes No

21. Completed by CO over the phone Yes No

· For help please call the conference organiser on (07) 3109 9131 or visit one of our offices.
· URGENT: This form must be sent back as soon as possible to help us deal with your matter quickly.

FAMILY DISPUTE RESOLUTION CONFERENCES

ADMINISTERED BY THE LEGAL AID QUEENSLAND

CONSENT by AGGRIEVED SPOUSE who is a

PARTY TO A PROTECTION ORDER

I,...... (name of aggrieved party) have obtained a current protection order against ...... (name of respondent).

The protection order is dated ...... (date order made) and will remain in force until ...... (date order expires).

I agree to attend a conference convened by Legal Aid Queensland so that I have the opportunity to resolve the dispute between the respondent and myself about:

(cross out which issues do not apply)

(a) Where the child/ren will live;

(b) How the child/ren will spend time or communicate

(d) financial matters including property settlement.

I understand that :

(a) the respondent is not in breach of the protection order (or the no contact clause within that order) by attending the conference; and

(b) the respondent is in breach of the protection order if an act of domestic violence is made towards me either before, during or after the conference.

I acknowledge that I have been advised by Legal Aid Queensland that I have the option of attending a face-to-face, separate room (“shuttle”), telephone or telephone shuttle conference.

Signature of Aggrieved Party: ......

Date: ......

The aggrieved party must sign this form and return it to Legal Aid Queensland “Attention: Dispute Resolution Services” before a conference can be held.

Conference No

TRIM no 2015/276754