- Independent Advocacy in the Tropics Inc

Service Request Form

Service Request Form WORD - PDF

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

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

Date Of Request

Requested By:
Self (Section A)Other Party (Section B)

Full Name

Street Address

Contact Number

Date of Birth

Age

Identifies as
MaleFemaleOther

Disability/Disabilities PLEASE DO NOT LIST YOUR MEDICAL OR HEALTH CONDITIONS

Cultural Background

Current Living Situation
OwnPrivate RentalPublic HousingHomeless

Is there a Public Guardian Appointed?
Yes No

Is there a Power of Attorney or Enduring Power of Attorney?
Yes No

Is the Public Trust appointed for financial management?
Yes No

Your Name / Organisation's name:

Your relationship with the person

Contact Number

e-mail

Does the person know and understand and consent to you making this referral?
Yes No

You will be contacted within ten (10) business days by the Intake Officer who will review the request, conduct an eligibility assessment and

discuss your options.

We may provide you self‐advocacy assistance or link you to an alternative service and/or organisation that is more suitable.

Please give a brief overview of why assistance is required AND what steps have been taken to resolve the matter/s