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Referral Advocate – Test Page

    Client Details


    Date of Birth

    Country of Birth

    Language spoken at home

    Has this person been a previous client of Advocacy WA?


    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



    Referrer's Position

    Additional Information

    I confirm that I have: