Individual Advocacy Form for Someone Else

Name of the person who needs support (required)

Date of Birth of the person who needs support (required)

Email of the person who needs support (if they have one)

Phone Number of the person who needs support (if they have one)

Postcode of the person who needs support (required)

Your Email (required)

Your Phone Number (required)

Your relationship to the person who needs support:

Advocacy Issue (please select from the drop down menu)

Disability Type (please select from the drop down menu)

Please provide a brief explanation of the support needed (required)

Who should we contact in the first instance? (required)

You The person who needs support

Advocacy