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Referral Advocate – Test Page

    Client Details

    Gender
    Date of Birth
    Country of Birth
    Language spoken at home
    Has this person been a previous client of Advocacy WA?
    Accommodation
    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?
    Is the client taking medication or other substances that may affect their mood or behaviour in any way?
    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
    Has the client given their authority to release information related to the Reason for Referral?
    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: