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Advocacy Referral Form (PDF)
Advocacy Brochure (PDF)
Prefix
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Preferred Name:
Pronouns
Choose an option
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Street Address
Street Address Line 2
City
State
Postcode
Phone
Email
Mobile Number
Preferred Method of Contact
What is your primary disability?
Are you an Australian citizen or permanent resident?
Yes
No
Do you identify as being:
Of Aboriginal and/or Torres Strait Islander background
Culturally and Linguistically Diverse
None of the above
Prefer not to disclose
What is the main language you speak a home?
Do you require an interpreter?
Yes
No
Do you sign, use a communication device, or use another form of assistance to communicate?
Yes
No
If yes, please provide details:
Do you have any other communication needs?
What is your primary source of income?
Employment
Disability Support Pension (DSP)
Compensation Payments
Job Seeker
No income
Other
Are you eligible for support with NDIS?
Yes, I have an NDIS Plan
Yes, I am waiting for my planning meeting
Unsure, I haven't applied yet
Unsure, I am awaiting outcome of Access Request
Unsure, I wish to reapply
No, I am not eligible
What are the issues that you are seeking Advocacy for?
Are there any safety concerns which Explorability should be aware of?
Please add the names and contact details of the legal guardians for th person under 18 years of age.
Do you have a Guardianship and/or Administration Order?
Yes
No
Select an option
The person with a disability seeking Advocacy Support
A family member or carer
Guardian or Administrator
Choice 4
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