Advocacy at Home Referral Form

After completing this referral form it will be allocated to the Advocacy at Home project. Depending on waiting times someone should be in touch with the person requiring advocacy support within two weeks. If the person does not meet the criteria for any of our services someone will be in touch with you as soon as possible to signpost to appropriate services.  The person MUST be 65 + to qualify for support from the Advocacy at Home Project.
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 the person requiring advocacy support

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* 2. What is the person's religion, if any?

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* 3. Which race/ethnicity best describes the person? 

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* 4. What is the person's sexual orientation?

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* 5. What gender does the person identify with?

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* 6. What is the person's language and/or preferred method of communication? (Makaton, gestures, pictures, etc.)

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* 7. What is the persons preferred methods of being contacted ?

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* 8. What best describes the person's current living accommodation ?

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

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

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* 11. Does the person have any disability/impairment?  If so, please state below.

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* 12. Who is the person making the referral?

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* 13. Please give reasons for the referral. What advocacy support do you feel the person requires?

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* 14. 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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