Independent Advocacy
Referral Form

Completing this form

*Mandatory fields MUST be completed.

Section 1: About the person who requires advocacy

Communication preference (tick all that apply):
Communication requirements or preferences:
Please select the best description of the individual's needs: *
Does the individual know anyone who can advocate further? (Family, friends, etc.):
This cannot be someone who has a conflict of interest, someone the individual doesn’t want involved, is unable to adequately offer support or is currently involved in an enquiry of abuse or neglect. *

Section 2: About the advocacy issue

Section 3: About the person referring - If you are referring yourself please put “self referral” in the first box and go to section 4

Section 4: Social Worker or Care Manager information

Section 5: Other professionals

Section 6: If you are supporting someone to make a self referral

Only complete this section if you are supporting someone to complete this form as a self referral. Skip to section 7 otherwise.

Section 7: Consent

Dewis CIL operates an open access policy on all records and we expect the individual to agree to a referral being made, providing they have the capacity to do so. This is important to ensure advocacy is effective, transparent and independent.