Issue 1
Advocacy Service
Advocacy support is a flexible support service aimed at helping people have a voice and ensuring
equal access to goods, services and opportunities.
Eligibility Criteria
• Individuals who have a disability
 Parents and/or carers of people, young and old, who have a disability
REFERRAL PROCESS
Referral Form to be completed with the applicant (form must be signed by applicant and referral agent (if
applicable).
Referral Form to be returned to AOD office at address listed below.
If the applicant meets the eligibility criteria the Advocacy worker will contact the applicant and referral agent
within 7 days of receiving the application.
Applicant and referral agent will be informed whether support can be provided.
There is an appeal process in place if the applicant / referral agent are unhappy with the decision.
CATEGORIES OF SUPPORT
Rights
1. Assistance in engaging with professionals and other relevant people or agencies e.g. doctors, social workers
2. Advice and guidance on entitlements and anti-discriminatory practices
3. Challenging inequalities and discriminatory practices
Physical Environment e.g.
1. Adaptations/equipment for disability
2. Access to services including buildings, transport
3. Ensuring emergency contact system is in place
Social Skills
4. Supporting the development of social networks and links with the community
5. Assistance in dealing with relationships and, where necessary, disputes
Financial and budgeting
1. Advice and/or assistance in dealing with social security benefits
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Issue 1
ADVOCACY SUPPORT REFERRAL FORM
Completed forms to be returned to: Action on Disability
689 Springfield Road
Belfast, BT12 7FP
Tel: 028 90 236677 Fax: 028 90 231074
1.
APPLICANT’S PERSONAL DETAILS
Name :____Mary McManus___________
(Mr/Mrs/Ms)
Address: _____689 Springfeild Rd Belfast_
Post code: ___BT12 7FP____ Tel: _90236677___
D.O.B: __31. 1. 1986____
2.
NEXT OF KIN/CARER
Name: ______Maura McManus________ Relationship:____mother_____
Address: ____________as above_____________________________________________
Post code: _____________ Tel: _________________
DOCTOR NAME ____Laverty______Surgery _Springfield Rd_____Tel_______________
3.
HOUSEHOLD MAKEUP
Name
Lives alone
Yes/No If no, list other occupants below
Relationship
Age
As above
6.
ECONOMIC STATUS
6.1 Employed/unemployed? Please circle
If employed, full-time/part time? Please circle
College/training? (Please specify) ___________________________
6.2. Please state type of benefits in receipt of: Income Support
JSA (IB)
Incapacity Benefit x DLA x Others ____________ ____________
Middle Rate Care x High Rate Care
7.
Low Rate Mobility
CATEGORIES OF SUPPORT REQUIRED
JSA (CB)
Low Rate Care
High Rate Mobility
(please tick all that apply)
Please refer to attached list.
1. Rights
x
2. Finances
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Issue 1
3. Physical Environment
x
4. Social Skills
x
4. Other please state
7.1 If ticked any of the above, please provide further information stating reason for
referral:___Mary has a moderate learning disability and physical disabilities and wants to move
into her own house. No contact can be made with the Learning Disabilities Floating Support
Service
OTHER AGENCIES / PROFESSIONALS INVOLVED
Social Worker x Housing Officer
Health Visitor/OT
9.
Probation
Community Support Worker
Other (please specify) __________________________________________
RELEVANT MEDICAL INFORMATION
______________Epilepsy____Cerebal palsy__________________
10.
Applicant CONSENT TO RECEIVE SUPPORT
I am willing to receive support, and work on a one to one basis with a Advocacy Worker.
I agree / do not agree (please delete) to the information on this form being passed to another
support provider if deemed more appropriate.
Signature: _____M McManus________
Date: ____20th Jan 2014______
If applicant is unable/unavailable to sign, please indicate they are aware of this referral yes
10.
REFERRAL AGENT’S DETAILS
Job Title ___________________________
Name Print: _Helen McAleese_Organisation: __SW LD_______ Telephone Number: ____
Email:[email protected]_______________
Address: ____Glendinning HOuse_____________________________________________
Relationship to applicant _______SW_______________
Length of time applicant known to referral agent: ____10 years_______
Priority Status:
Urgent/Non Urgent
Have you referred this client to another support service?
Yes
x
No
If yes, please state ________________________________________________
Signed Agency: ____________________
Date: ________________
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