Skip to main content
Search
Search
Home
Accessibility
News
Who we are
About us
Our people
Partnerships
Membership
What we do
Individual Advocacy
Systemic Advocacy
Self-advocacy
Projects & Programs
Training & Consultancy
Community Hub
Case studies
Do you need help?
Contact
Menu
Who we are
About us
Our people
Partnerships
Membership
What we do
Individual Advocacy
Systemic Advocacy
Self-advocacy
Projects & Programs
Training & Consultancy
Community Hub
Case studies
Do you need help?
Contact
Make A Referral
To make a referral for Individual Advocacy, complete the referral form below. To make an appointment with an Advocacy Officer, phone 08 9388 7455 or 1800 659 921 to speak with the Manager for Advocacy Services.
‘
*
‘ indicates required fields
Referral Details
Is this Referral Form completed by
Myself
A Parent, Carer or Guardian
An Agency
Your details
If you go by one name, please enter in both Given Name and Last Name
Given Name
Enter your given name, names or common name
Preferred Name
Enter your preferred name
Last Name
Enter your last name
Gender
Man or male
Woman or female
Non-binary
[I/They] use a different term
Not stated
Other
Address
Enter street number and street
Suburb
Enter suburb
Post Code
Enter post code
State
Enter state
Phone number
Enter phone number
Home phone number
Enter home number
Email
Enter your email address
Date of birth
Estimated Age if Date of birth is unknown
Date of birth
dd/mm/yyyy
Estimated Age
Enter years or 1 if client is under 1 year of age
Ethnicity
Enter your ethnicity
Disability / Illness
Enter your disability / illness
Reason for referral
Please describe the reason for referral
Do you require an interpreter?
Yes
No
In what language?
Enter your main language
I provide consent for Kin Disability Advocacy to collect and store my personal information given in this referral in accordance with their online
Privacy Statement
.
The client’s details
If the client goes by one name, please enter in both Given Name and Last Name
Given Name
Enter the client’s given name, names or common name
Preferred Name
Enter the client’s preferred name
Last Name
Enter the client’s last name
Gender
Man or male
Woman or female
Non-binary
[I/They] use a different term
Not stated
Other
Address
Enter the client’s street number and street
Suburb
Enter the client’s suburb
Post Code
Enter the client’s post code
State
Enter the client’s state
Phone number
Enter the client’s phone number
Home phone number
Enter the client’s home number
Email
Enter the client’s email address
Date of birth
Estimated Age if Date of birth is unknown
Date of birth
dd/mm/yyyy
Estimated Age
Enter years or 1 if client is under 1 year of age
Ethnicity
Enter the client’s ethnicity
Disability / Illness
Enter the client’s disability / illness
Reason for referral
Please describe the reason for the client’s referral
Does the client require an interpreter?
Yes
No
In what language?
Enter the client’s main language
Your details
Given Name
Your given name, names or common name
Last Name
Your last name
Phone
Email Address
Do you require an interpreter?
Yes
No
In what language?
What is your relationship with the client?
Parent
Carer
Guardian
I have the consent of the client or authority to make this referral on their behalf.
This includes that they are aware that Kin Disability Advocacy will collect and store their information, and information about the person making the referral, in accordance with their online
Privacy Statement
.
The client’s details
If the client goes by one name, please enter in both Given Name and Last Name
Given Name
Enter the client’s given name, names or common name
Preferred Name
Enter the client’s preferred name
Last Name
Enter the client’s last name
Gender
Man or male
Woman or female
Non-binary
[I/They] use a different term
Not stated
Other
Address
Enter the client’s street number and street
Suburb
Enter the client’s suburb
Post Code
Enter the client’s post code
State
Enter the client’s state
Phone number
Enter the client’s phone number
Home phone number
Enter the client’s home number
Email
Enter the client’s email address
Date of birth
Estimated Age if Date of birth is unknown
Date of birth
dd/mm/yyyy
Estimated Age
Enter years or 1 if client is under 1 year of age
Is the client’s Date of Birth unknown by the Agency or by the client?
Agency
Client
Ethnicity
Enter the client’s ethnicity
Primary Disability / Illness
Please select…
Acquired Head Injury
Autism
Blind/Visual Impairment
Cognitive Impairment (including FASD)
Deaf/Hearing Impairment
Developmental Delay
Global Developmental Delay
Intellectual
Medical
Neurological
Not stated/inadequately described
Physical
Psychosocial
Specific Learning
ADHD
Speech
Enter the client’s primary disability / illness
Secondary Disability / Illness
Please select…
Acquired Head Injury
Autism
Blind/Visual Impairment
Cognitive Impairment (including FASD)
Deaf/Hearing Impairment
Developmental Delay
Global Developmental Delay
Intellectual
Medical
Neurological
Not stated/inadequately described
Physical
Psychosocial
Specific Learning
ADHD
Speech
Enter the client’s secondary disability / illness
Reason for referral
Please describe the reason for the client’s referral
Does the client require an interpreter?
Yes
No
In what language?
Enter the client’s main language
The Agency’s details
Agency
Enter referring agency
Referrer’s Given Name
Referrer’s given name, names or common name
Referrer’s Last Name
Referrer’s last name
Phone
Enter your phone number
Email Address
Enter email address
Other Information
Additional referral details including primary contact information and relationship to client (if relevant).
Would you like feedback
Yes
No
Are any of the following risk factors known about the client’s circumstances or environment that may impact on service delivery?
Family domestic violence
Contagious disease
Alcohol and other drugs
Aggressive behaviour
Pets, other residents, and other access issues
Other (please describe)
None
Other (please describe)
I have the consent of the client to make this referral on their behalf. They have been made aware of, and consent to, Kin Disability Advocacy collecting and storing their information in accordance with their online
Privacy Statement
.
As the person making the referral, I also provide consent for Kin Disability Advocacy to collect and store my personal information given in this referral in accordance with their online
Privacy Statement
.
Contact Information
