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Who is the advocacy for?

First name

Last name

Date of birth

Gender

Email

Telephone no

Placement

Which local authority is the social work department from?

Ethnicity

Disability Hold down the ctrl button to select multiple options

Postcode

Address line 1

Address line 2

Address line 3

Town

Postcode

Geographical Local Authority

Is this referral related to a Child Protection Process?

If the young person received advocacy in the past, let us know who their advocacy worker was

Briefly, tell us why you think the young person needs advocacy

First name

Last name

Email

Telephone no

Postcode

Address line 1

Address line 2

Address line 3

Town

Postcode

What's your relationship to the young person

By ticking here, you are confirming that the person you are referring knows you are making the referral and that you are sharing their details with us

Is there an upcoming meeting/hearing for which advocacy is needed

Date of upcoming meeting/hearing

Is Young person address is a non-disclosure address

Please explain why you are sharing a non-disclosure address and advise whether it is safe for us to visit the child/young person there. If it is not appropriate to share the non-disclosure address, please put c/o referrer in the address box in Section 2

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