Make a Referral

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

MyselfA Parent, Carer or GuardianAn 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 maleWoman or femaleNon-binary[I/They] use a different termNot stated

Other

Ethnicity

Enter your ethnicity

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

Enter your email address

Date of birthEstimated Age if Date of birth is unknown

Date of birth

dd/mm/yyyy

Estimated Age

Enter number of years i.e. 40, or 1 if client is under 1 year of age

Disability / Illness

Enter your disability / illness

Reason for referral

Please describe the reason for referral

Do you require an interpreter?

YesNo

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 maleWoman or femaleNon-binary[I/They] use a different termNot 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

Enter the client’s email address

Date of birthEstimated 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?

YesNo

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?

YesNo

In what language?

What is your relationship with the client?

ParentCarerGuardian

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 maleWoman or femaleNon-binary[I/They] use a different termNot 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

Enter the client’s email address

Date of birthEstimated 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?

AgencyClient

Ethnicity

Enter the client’s ethnicity

Primary Disability / Illness

Enter the client’s primary disability / illness

Secondary Disability / Illness

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?

YesNo

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

YesNo

Are any of the following risk factors known about the client’s circumstances or environment that may impact on service delivery?

Family domestic violenceContagious diseaseAlcohol and other drugsAggressive behaviourPets, other residents, and other access issuesOther (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

Make a Referral

Make A Referral

Kin | Disability Advocacy for Diverse Communities

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