Intake Form | Lcpinc

First Name (Include alias and preferred names if applicable)

Last Name

Date of Birth

Gender Identity (include any preffered pronouns)

Preferred Language

Phone

Address (if applicable)

Do you identify as any of the following:

Aboriginal

Torres Strait Islander

Prefer not to say

Do have immediate concerns for your safety? Call 000 if your life is in danger.

Do you have somewhere safe to stay tonight?

How are you hoping LCP can help?

Do you have children under your care? If so please provide their names and age.

Please select the ways we may contact you

It is safe to communicate with me via email

It is safe to communicate with me via the phone number provided

Please DO NOT contact me using the deatils provided as it may put my safety at risk

Thanks for providing your details! Someone from our team will be in contact within 48 hrs. For any urgent matters please call us on 1800 664 996