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Self Referral

Use this form to refer yourself or someone you know to Integrated Disability Action (IDA) for advocacy support. If you need help completing the form, please contact us.

Client Contact Information

Please provide your contact details so we can get in touch with you about your referral.
Name(Required)
Address(Required)
DD/MM/YYYY
Male, female, non-binary etc.
The country you were born.
Do you identify as a person with disability?(Required)

Access Needs

Please let us know if you have any access requirements.

Advocacy Enquiry

Please tell us about the concerns you are experiencing and what outcome you would like to achieve through advocacy support.
Could you please provide a summary of the advocacy issue, including who is involved, what happened, when it occurred, and where it took place?
What outcome or result would you like to achieve?

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.
Who is completing this form?(Required)

Do you have permission to discuss this advocacy issue on behalf of the person it relates to?(Required)
Clear Signature
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.
DD/MM/YYYY