Dudley Advocacy Referral Form-Volunteers

Volunteers Referral Form

After completing this referral form it will be allocated to the volunteer advocacy 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.

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

Name *

Date of Birth *

Address *

Postcode *

Email Address

Phone Numbers *

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

Christian

Buddhist

Hindu

Jewish

Muslim

Sikh

None

Prefer not to say

Other (please specify)

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

White/White British

Black/Black British

Asian/Asian British

Mixed race

Rather not say

Another race or ethnicity (please specify)

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

Asexual

Bisexual

Gay

Heterosexual or straight

Lesbian

Pansexual

Queer

Prefer not to say

None of the above, please specify

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* 5. What gender does the person identify with?

Female

Male

Trans-female

Trans-male

Genderqueer/gender nonconforming

Prefer not to say

Other (please specify)

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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 ?

Any

Landline

Mobile

Post

Face to Face meetings

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* 8. What best describes the person's 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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* 9. 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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* 10. Has the person given you consent to make this referral?

Yes

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* 11. To match people to the right support services, which of the following best describes the persons disability/impairment.
(Please note if the person does not have one of the listed disabilities/impairments they are not eligible.)

Learning Disability - mild to moderate

Learning Disability - complex to severe

Learning Disability - Profound & Multiple Learning Disabilities

Autistic Spectrum

Parent(s) with a learning disability

If more than one section is applicable please state others here

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* 12. Who is the person making the referral?

Name *

Relationship to person *

Address *

Postcode

Email Address

Phone Numbers *

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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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* 15. Do you know the preferred places and 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 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. To match people to the right support services, which of the following best describes the persons disability/impairment. (Please note if the person does not have one of the listed disabilities/impairments they are not eligible.)

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

* 11. To match people to the right support services, which of the following best describes the persons disability/impairment.
(Please note if the person does not have one of the listed disabilities/impairments they are not eligible.)

* 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):