Agency Referral Form

This form is for agencies, service providers, or support organisations referring a person to Integrated Disability Action (IDA) for advocacy support. Please ensure the person being referred has given consent for the referral and understands the purpose of advocacy support.

Client Contact Information

Please provide your clients contact details so we can get in touch with them about your referral.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Email(Required)

Phone(Required)

Is your client a resident of the Northern Territory?(Required)

YesNo

Date of birth

DD/MM/YYYY

Gender

Male, female, non-binary etc.

What is your clients nationality?

What is your clients cultural background?

Does your client identify as a person with disability?(Required)

Yes – physical disability

Yes – sensory disability (vision, hearing etc.)

Yes – intellectual or cognitive disability

Yes – psychosocial or mental health condition

Yes – neurodivergent (e.g. autism, ADHD)

No

Prefer not to say

Other

Could you please tell us about your client's disability and how it affects their daily life?

Access Needs

Please let us know if your client has any access requirements.

What is your clients first language?

Does you client require an interpreter?

Does your client have any access needs or supports?

Advocacy Enquiry

Please tell us about the concerns you are experiencing and what outcome you would like to achieve through advocacy support.

Brief Summary(Required)

Could you please provide a summary of the advocacy issue, including who is involved, what happened, when it occurred, and where it took place?

Desired Outcome(Required)

What outcome or result would your client like to achieve?

Referring Agency/Organisation Details

Business Name(Required)

Name(Required)

First Last

Job Title(Required)

Email(Required)

Phone(Required)

Relationship to client(Required)

Consent & Privacy

In this section we will confirm whether the person completing this form is authorised to discuss the advocacy issue on behalf of the individual it relates to.

Do you have permission to discuss this advocacy issue on behalf of the person it relates to?(Required)

Yes - consent is attached

No

Not sure

Has your client consented to this referral?(Required)

Yes - consent is attached

No

Proof of consent to act on behalf of your client

Accepted file types: pdf, jpeg, png, Max. file size: 512 MB.

Signature(Required)

Please sign here to confirm that the information you have provided is true and correct to the best of your knowledge and that you have consent or authority to discuss the advocacy issue or issues outlined above.

Date Signed(Required)

DD/MM/YYYY