My Side Volunteer Advocacy

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Referrer Details / Organisation

Referrer Name(Required)

First Last

Taken by

Referrer Address

Street Address Address Line 2 City ZIP / Postal Code

Tel No

Email Address

Role

How did you hear about us?

Has the individual had advocacy before?

Yes

If yes, is it the same issue?

Yes

Nature of Disability

Details of Person Requiring Advocacy

Name of Person(Required)

First Last

Tel No

Address

Street Address Address Line 2 City ZIP / Postal Code

Date of Birth

Specific Communication Needs

If English is not spoken, please indicate language spoken

Does the person want an advocate?

Yes

Unknown

Risk Assessment

Are there any known risks to the advocacy worker? (Select all that apply)

Drug User

Location Risk

Alcohol

Dependent

Animals

Smoker

Aggressive Behaviour

Person requires a 2-person visit

Please expand on any risks if necessary

Supporting Contacts

Name and contact details of Social Worker / Professional involved

Next of Kin / Family Member

Doctor’s Name, Address and Tel Number

Reason for Referral

Why does this person need an advocate?(Required)

Please provide concise, factual, specific details.

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