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 on Ask Izzy at askizzy.org.au/disability-advocacy-finder.

Part A. Participant details

• First name and last name
• Contact number and email

Part B. Advocate or support person details

• First name, last name and date of birth
• Contact number and email
• Address, suburb and postcode
• Relationship to the participant
• Preferred method of communication: phone or email

Roles and responsibilities

The nominated advocate or support person may support the Participant with Disability and Mental Health Care Pty Ltd by:

• Assisting in communication with Disability and Mental Health Care Pty Ltd.
• Being a point of contact and liaising with Disability and Mental Health Care Pty Ltd 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 or support person for the purpose of providing support and advocacy.
• The Participant understands that the advocate or support person will be provided access to personal and sensitive information in order to fulfil their role.
• The advocate or 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 or support person understand that this arrangement can be terminated or modified at any time by either party, upon written notice.

Declarations

Declaration by the Participant: I declare that I have appointed the representative, advocate or support person named in Part B of this form. Signed and dated by the participant.

Declaration by the 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. Signed and dated by the representative.

The form is also signed and dated for and on behalf of Disability and Mental Health Care Pty Ltd by its named representative.