CONTACT US – FOR SERVICE PROVIDERS Service Provider First Name Service Provider Last Name Occupation Organisation Name Service Provider Email Address Service Provider Phone Number Client First Name Client Last Name Client Date of Birth Is the client currently experiencing financial hardship? NoYes – client receives Centrelink benefitYes – client does not have means to payYes – client cannot access finance temporarilyYes – OtherUnknown What is the client’s psychiatric diagnosis? Has the client consented to be referred to MHLC? YesNo Does the client currently have legal representation? YesNo Please describe the client’s legal issue:
