Help for someone else

Consent to refer(Required)

Important: The person you are referring MUST have agreed to you making the referral on their behalf. If you haven’t spoken to the person and obtained their consent do not complete the form as we are unable to contact them without their consent. If you need more information about this please call us on Free call 1800 005 131 to discuss how client directed advocacy works.

For further information refer to our privacy policy located here - https://advocacytasmania.org.au/wp-content/uploads/2024/03/Privacy-and-Complaints-5-Feb-2019-WEB.pdf

Confirming consent by checking the box below will enable the rest of the form.

I have obtained consent from the person being referred

Referring Persons Details

Referrer name(Required)

First Last

Referring Organisation

If you are a service provider or other organisation

Job title

Phone

Relationship to client

Client consent date

When did the client provide consent?

Has the client provided consent for us to leave a message?

If the client has not provided consent for us to leave a message, we will attempt to contact them multiple times.

Yes

Preferred contact method

Are there any days/times we shouldn't call?

Which category does the person best fit?(Required)

We only work with Tasmanian clients who are older people, people with disability, or people experiencing mental health, alcohol/other drugs issues.

Issue Description(Required)

In a few sentences outline the issue the person needs support to resolve e.g accessing NDIS, supports for aged care/disability/mental health or alcohol/other drugs services, guardianship/ administration, abuse, complaint, discrimination, communicating with service providers or doctors (50 words limit)

Person being referred

Name

First Last

Phone

Suburb

Preferred contact method

Does the person need to be contacted through a third party?

Yes

E.g. relative, service provider,

Third party relationship

Does the person need an interpreter

Yes

Language

Help for someone else.