Intake Form | Lcpinc

LCP Intake Form

To apply for assistance we require the following information.

First Name (Include alias and preferred names if applicable)

Last Name

Gender Identity (include any preffered pronouns)

Date of Birth

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: Required

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 details provided as it may put my safety at risk

I consent to my information being collected and documented by LCP staff to assist me with my assessment and case management goals. This information shall not be shared elsewhere without my consent, unless there are significant safety risks which require LCP to share limited information to ensure my personal safety, safety of children, others, or disclosure of any major criminal activity.