- Independent Advocacy in the Tropics Inc

1800 887 688

Request for Service Form

Request for Service Form WORD - PDF

PLEASE USE 1 FORM PER PERSON
ENSURE YOU ENTER CORRECT CONTACT DETAILS

Date of Request

Requested By:

On own behalf By another party

SECTION A – DETAILS OF PERSON REQUIRING ASSISTANCE

Full Name

Street Address

Telephone

Date of Birth

Age

Gender

Male Female Non-Binary

List all Diagnosed Permanent Disabilities:
PLEASE DO NOT LIST COMPLEX MEDICAL OR HEALTH CONDITIONS

Indigenous Status:

Neither Aboriginal nor Torres Strait Islander Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander

Cultural Background:

English Speaking Background Non-English Speaking Background English as 2nd Language

Language Spoken at Home

NDIS Participant:

Yes No Currently Seeking Access

Current Living Situation

Own Private Rental Public Housing Group Home Homeless Other

Describe living situation if other

Appointed Decision Makers:

Power of Attorney/Enduring Power of Attorney Office of Public Guardian/Other QCAT appointed Guardian Public Trustee/Other QCAT Appointed Financial Administrator NDIS Plan Nominee

SECTION C – ISSUE/S

Please give an overview of why advocacy is needed

SECTION D – STEPS ALREADY TAKEN

Please describe of what steps have already been taken to try and resolve these issue(s)

SECTION E - OUTCOMES SOUGHT

Please describe the outcomes you want an advocate to help you achieve

SECTION F – TIME FRAME OF NEED FOR ADVOCACY

If any of your issues need to be addressed by a particular date, please list the date(s) here

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