Strivesocial: Advocate or Support Person Request Form

Written By Julie Athanasiou

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.


PART A: PARTICIPANT DETAILS

First Name:

Last Name:

Contact Number:

Email:


PART B: ADVOCATE OR SUPPORT PERSON DETAILS

First Name:

Last Name:

Date of Birth:

Contact Number:

Email:

Address:

Suburb:

Postcode:

Relationship to Participant:

Preferred method of communication:

☐ Phone

☐ Email


ROLES AND RESPONSIBILITIES

The nominated advocate or support person may support the Participant with Strivesocial by:

  • Assisting in communication with Strivesocial

  • Being a point of contact and liaising with Strivesocial 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:

Signature:

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:

Signature:

Date:



Signed for and on behalf of Strivesocial


Strivesocial’s Representative Name:

Signature:

Date:



Julie Athanasiou
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Strivesocial: Feedback and Complaints Form