Advocacy Referral Form

Referral for Advocacy Support

Please fill in the details below
Personal details of a person with the disability
Name*

PrefixFirst NameLast Name
Preferred Name:
Preferred name to be called
Date of Birth:*

DayMonthYear
Gender:*
Address:*

Street Address

Street Address Line 2

CityState

Postcode
Home Number:
Mobile Number:
E-mail:
Preferred Method of Contact:*
How would you like us to contact you (e.g. telephone, email, text message)
What is your primary disability?*
Are you an Australian citizen or permanent resident?

YesNo
Do you identify as being:

Of Aboriginal and/or Torres Strait Islander backgroundCulturally and Linguistically DiverseNone of the abovePrefer not to disclose
What is the main language you speak at home?
Do you require an interpreter?

YesNo
Do you sign, use a communication device or use another form of assistance to communicate?

YesNo
If yes, please provide details:
Do you have any other communication needs?
What is your primary source of income?

EmploymentDisability Support Pension (DSP)Compensation PaymentsJob SeekerNo incomeOther
Are you eligible for support with NDIS?*

Yes, I have an NDIS PlanYes, I am waiting for my planning meetingUnsure, I haven't applied yetUnsure, awaiting outcome of Access RequestUnsure, I wish to reapplyNo, I am not eligible
What are the issues that you are seeking Advocacy for?*
Are there any safety concerns which Explorability should be aware of? Please note this does not affect access to advocacy from Explorability.*
For individuals under 18 years of age:
Please add the names and contact details of the legal guardians for the person under 18 years of age.
Please indicate preferred method of contact, such as telephone or email.
For individuals 18 years or over:
Do you have Guardianship and/or Administration Order?
Please provide the name and contact details of those who are responsible for managing your affairs (e.g. Guardian, Administrator).
Please attach a copy of any Guardianship and Administration Orders, if applicable.

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Is the person completing this form:*

The person with a disability seeking advocacy supportA family member or carerGuardian or AdministratorService ProviderLocal Coordinator or other government employeeOther
Collection, storage and release of information

Explorability collects and securely stores personal information during the referral process to ensure a high quality of service.

Explorability will only provide your personal information to, or discuss your situation with, individuals or organisations where:

·         you (or your guardian, where applicable) have given your consent

·         it would put you or another person at risk if the information was not released.

·         Explorability is required to do so by law

All personal information is protected under the Commonwealth Privacy Act 1988. De-identified information is provided to Department of Communities regarding the service and hours provided, age, disability and cultural background.

Consent remains valid for the duration of the service, and you have the right to withdraw consent at any time.
For individuals seeking advocacy, please sign below
Plesae tick below to indicate that you agree to this referral, including the collection, storage and release of information as outlined above*

YesNo
Signature:*

Clear
Date*

DayMonthYear
Date
For referrers: Please complete the following
Name and contact details of referrer
Please sign to confirm that the person/guardian has consented to this referral, including the collection, storage and release of information as outlined above

Clear
Date

MonthDayYear
Date
Once you submit this form, it will be reviewed by Explorability. A staff member will be in contact with you within five working days to discuss your referral.
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Referral for Advocacy Support

For individuals seeking advocacy, please sign below

For referrers: Please complete the following