Advocate or Support Person Request Form

This form is to be completed if you wish to nominate a representative, advocate or support person to provide support. Examples of representatives, advocates or support persons may include parents, relatives or legal representatives.

Advocates in the local area can be found using the Disability Advocacy Finder here: Disability Advocacy Finder | Ask Izzy.

PARTICIPANT DETAILS

First Name *

Last Name

Contact Number: *

Email Address: *

ADVOCATE OR SUPPORT PERSON DETAILS

First Name *

Last Name

Date of Birth: *

Contact Number: *

Email Address *

Street Address *

Suburb: *

Postcode: *

Relationship to Participant: *

Preferred method of communication: *PhoneEmail

ROLES AND RESPONSIBILITIES

The nominated advocate or support person may support the Participant with Enable, Independent Living, Housing and Support Services by:

Assisting in communication with Enable, Independent Living, Housing and Support Services
Being a point of contact and liaising with Enable, Independent Living, Housing and Support Services on behalf of the Participant
Ensuring information is understood
Accompanying the Participant during service-related activities if required
Representing the Participant’s best interests

CONFIDENTIALITY AND CONSENT

The Participant acknowledges and consents to the sharing of relevant information with the advocate/support person for the purpose of providing support and advocacy.
The Participant understands that the advocate/support person will be provided access to personal and sensitive information in order to fulfill their role.
The advocate/support person acknowledges their responsibility to maintain the confidentiality of the Participant’s information and to act in the best interests of the Participant.
The Participant and advocate/support person understand that this arrangement can be terminated or modified at any time by either party, upon written notice.

DECLARATIONS

Declaration by Participant

I declare that I have appointed the representative, advocate or support person named in Part B of this form.

Participant’s Name: *

Date: *

Declaration by Representative

I declare that I have been appointed by the Participant named in Part A of this form as a representative, advocate or support person

Representative’s Name: *

Date: *

Signed for and on behalf of Enable, Independent Living, Housing and Support Services

Enable, Independent Living, Housing and Support Services’

Representative Name: *

Date: *