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16 November 2023
Disclosure Scotland – Did you know?
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Who is the advocacy for?
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First name
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Date of birth
Gender
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Male
Female
Non-Binary
Transgender
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I’d prefer to use my own term
Email
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Placement
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Not care experienced
At home with parents
With friends/relatives
Foster carers purchased by LA
Foster carers provided by LA
Permanent placement with prospective adopters
In other community
In Local Authority home
In children’s home
In residential school
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Crisis care
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Homeless
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In own tenancy/independent living
Prison
Which local authority is the social work department from?
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Aberdeen
Aberdeenshire
Angus
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Clackmannanshire
Dumfries and Galloway
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East Lothian
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Midlothian
Moray
North Ayrshire
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Orkney
Perth and Kinross
Renfrewshire
Shetland
South Ayrshire
South Lanarkshire
Stirling
The Scottish Borders
West Dunbartonshire
West Lothian
Western Isles
Other
Ethnicity
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African, Scottish African or British African
Caribbean or Black
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Disability Hold down the ctrl button to select multiple options
No or no known disability
Prefer not to say
Blindness or partial sight loss
Learning disability(e.g.Down’s Syndrome)
Learning difficulty(e.g.Dyslexia)
Developmental disorder(e.g.Autistic Spectrum Disorder or Asperger’s Syndrome)
Physical disability
Mental health condition
Long-term illness, disease or condition
Other
Other
Postcode
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Address line 1
Address line 2
Address line 3
Town
Postcode
Geographical Local Authority
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Aberdeen
Aberdeenshire
Angus
Argyll and Bute
Clackmannanshire
Dumfries and Galloway
Dundee
East Ayrshire
East Dunbartonshire
East Lothian
East Renfrewshire
Edinburgh
Falkirk
Fife
Glasgow
Highland
Inverclyde
Midlothian
Moray
North Ayrshire
North Lanarkshire
Orkney
Perth and Kinross
Renfrewshire
Shetland
South Ayrshire
South Lanarkshire
Stirling
The Scottish Borders
West Dunbartonshire
West Lothian
Western Isles
Other
Is this referral related to a Child Protection Process?
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Yes
No
If the young person received advocacy in the past, let us know who their advocacy worker was
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Postcode
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Address line 2
Address line 3
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Third Sector organisation
Social Worker
Parent
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LAC nurse
Foster carer
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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
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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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