Dudley Advocacy Referral Form - Complex Needs Advocacy

Complex Referral Form

After completing this referral form, it will be processed by the Complex Needs Advocate. If the person does not meet the criteria for any of our services someone will be in touch with you to signpost to appropriate services. If you are unsure on any of the questions please do not hesitate to contact us on 01384 456877 or at info@dudleyadvocacy.org.

Easy read versions of this form are available on request.

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* 1. Details of person requiring advocacy support

Name *

Date of Birth *

Address *

Postcode *

Ethnicity

Sexual Orientation

Religion

Email Address

Phone Numbers *

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* 2. Gender?

Female

Male

Transgender

Prefer not to say

Other (please specify)

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* 3. What is the client’s language and/ or preferred method of communication? (Makaton, gestures, pictures, etc.)

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* 4. Preferred methods of being contacted ?

Any

Landline

Mobile

Post

Face to Face meetings

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* 5. What best describes the persons current living accommodation ?

Own Home

Supported Living

Living with family

Care Home

Shared Lives

Respite

Residential Home

Hospital

Prison

Unknown

Other (please specify)

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* 6. Does the person understand the reason for the referral ?

Yes

Unsure

If you clicked no or unsure can you give reasons why

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* 7. Has the person given you consent to make this referral ?

Yes

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* 8. To match people to the right support services, which of the following best describes the persons disability / impairment

Learning Disability - mild to moderate

Learning Disability - complex to severe

Learning Disability - Profound & Multiple Learning Disabilities

Autistic Spectrum

Parent(s) with a learning disability

Mental Health

Other

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* 9. Who is the person making the referral ?

Name *

Relationship to person *

Address *

Post code

Fax

Email Address

Phone Numbers *

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* 10. Please give reason for referral ? what advocacy support do you feel the person requires ?

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* 11. Does the client or environment that they are in pose any risks to the advocate?
(detail any risk management procedures that are in place. This can be in relation to both risks from people and physical environment):

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* 12. Do you know the preferred places & times the person would feel at ease meeting the advocate ?

Home

At a public building

At Dudley Advocacy's offices

Not sure

please give preferred days and times if possible

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* 1. Details of person requiring advocacy support

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* 2. Gender?

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* 3. What is the client’s language and/ or preferred method of communication? (Makaton, gestures, pictures, etc.)

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* 4. Preferred methods of being contacted ?

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* 5. What best describes the persons current living accommodation ?

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* 6. Does the person understand the reason for the referral ?

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* 7. Has the person given you consent to make this referral ?

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* 8. To match people to the right support services, which of the following best describes the persons disability / impairment

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* 9. Who is the person making the referral ?

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* 10. Please give reason for referral ? what advocacy support do you feel the person requires ?

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* 11. Does the client or environment that they are in pose any risks to the advocate?(detail any risk management procedures that are in place. This can be in relation to both risks from people and physical environment):

Question Title

* 12. Do you know the preferred places & times the person would feel at ease meeting the advocate ?

* 11. Does the client or environment that they are in pose any risks to the advocate?
(detail any risk management procedures that are in place. This can be in relation to both risks from people and physical environment):