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SWAN can only accept a referral if the person needing an advocate has given their consent.
Please complete all sections otherwise the referral will be returned to you and will delay the referral being processed.

This form is for referrals to the following advocacy services;
• Continuing Health Care (CHC)
• Carers Advocacy
• Parents with Learning disabilities
• General Advocacy

Are you asking for an advocate for yourself? (required)

If you are asking for an advocate for someone else, have they given their consent?

May we contact the client directly?

Referrer Information (if other than the client)

Address

Client Information (the client is the adult who requires an advocate)

Date of birth (required)

Address at point of referral (e.g. hospital)

Home address (if different from above)

Does the client have any special needs we should consider when visiting, or arranging to meet with them, (eg. do they have difficulty in communicating verbally/in writing?) (Required)

During the advocacy process will the client have difficulty communicating their views and feelings/have difficulty retaining information/understanding information/weighing up the information? (Required)

Are there any risks that we should be aware of when visiting or arranging to meet with the client? eg. Pets at the home, Substance/Tobacco use, Behavioural issues, Neighbourhood concerns, Risk of self harm/Suicide, other members of the household (Required)

Please indicate which area of advocacy is required (please select all that relate):

Pan-Dorset: general issues advocacy for individuals receiving a commissioned service from the local authority

Continuing Healthcare Advocacy

Carers Advocacy

Parents with Learning Disabilities (please also send a spot purchase form)

Please state briefly what you feel the advocacy issue to be (Required)

Are there any deadlines or important meeting dates?

I consent to this referral and authorise SWAN to hold my/the individual's personal information (including the information provided on this referral)

Where referrals are made by a third party – written contact with the client will be made within 3 working days of receipt of this form, though it may take longer to allocate an advocate.

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