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About the Person
A / Name of the Person:
B / Please describe the specific reasons why you are requesting advocacy support:
C / Current Place of Residence (at date of referral):
D / Tel No: / Date of Birth:
Email Address
E / Eligibility Checklist
Partners must be:
Currently resident in Doncaster Borough
And
Over 18 years old
And
Has a social or health care service issue
And at least one of the following;
  1. An older person
  2. Has a physical disability
  3. Has a sensory disability
  4. Has a learning disability
  5. Has mental health issues
  6. Is an adult carer
  7. A person in transition into adult services
  8. A person with social care needs
/ Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Risk and Support Needs
F / Support Needs - Please detail any support needs the advocate needs to be aware of to provide advocacy e.g. Any long term condition, Impairment, Language or preferred communication methods:
G / Risks - Please detail any information needed to ensure the safety of the advocate and the referred person during the advocacy:
Key People
H / Referred by: Other / Self / Professional / Other
If you are making a referral on behalf of another person please provide your details: / Print Name
Position or Relationship to person
Organisation
Tel No
Mobile No
Fax No
Email
I / If you are making a referral on behalf of another person, is the person aware of the referral? / Yes No
If no, please outline reasons for this
J / Involved professionals & contact details
(if relevant):
K / Signature (Referrer) / Date
Time

Post:

VoiceAbility Doncaster

24-26 Wood Street

Doncaster

DN1 3LW

Email:

fax:

01302 319052

Advocacy Referral Form – March 2012

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