Referral Advocate – Test Page

Gender
MaleFemaleTransgenderIntersex/IndeterminateNot States or Inadequately Described

Date of Birth

Country of Birth

Language spoken at home

Has this person been a previous client of Advocacy WA?
YesNoUnknown

Accommodation
Boarding House/Private HotelHospitalNo Usual ResidencePrivate OwnedPrivate ResidencePublic HousingResidential Aged CareSupported Accommodation FacilityOther

Disability / Mental Health Condition (if known)

What is the functional impact of the disability / condition?

Please provide names and contact details of important others (carers, support agency, GP, housing provider, legal representative).

Are you aware if the client presents any risk of harm or violence to self, to others or to a staff member?
YesNoI'm Unsure

Is the client taking medication or other substances that may affect their mood or behaviour in any way?
YesNoI'm Unsure

Please list any upcoming appointments, deadlines or Court hearings that we may need to be aware of.

Reason for Referral (attach additional pages if required)

More information (optional)

Client Consent

Has the client or their guardian given their consent to this referral?
Advocacy WA cannot accept referral without client consent
YesNo

Has the client given their authority to release information related to the Reason for Referral?
Yes - VerbalYes - Written consent(please attach or forward signed consent form to admin@advocacywa.org.au)No

Attach Consent Form

Date of Verbal Consent

Information permitted for exchange is in relation to:

Agency Details

Referrer's Name

Contact Number

Email

Agency

Referrer's Position

Additional Information

I confirm that I have:
Read the Guidelines for ReferralProvided all information relevant to the issueProvided all information relevant to the safety of the client and/or staff membersSought the client's consent and attached a Release of Information form (where applicable)