INITIAL REFERRAL FORM SEDAS South East Disability Advocacy Service 71 Suttontown RD Mount Gambier SA 5290 (08) 87236002 Fax: (08) 87258009 SEDAS South East Disability Advocacy Service Date of Referral: ........./......./......... DOB: ......../......./....... Gender: Male [ ] Female [ ] IS THIS REFERRAL [ ] New [ ] Re referral Name: ............................................................................................................................. Address:..................................................................................................................... Phone Number: ............................................................................................................... Disability type:............................................................................................................. Ethnic Origin: ................................................................................. Language spoken at home: .......................................................... Interpreter required: ................................................................... WHO IS MAKING THE REFERRAL? DETAILS OF REFERRER: [ ] Person with a disability Name: ...................................................................... [ ] Carer / family member Relationship to client: ............................................. [ ] Friend Telephone: ................................................................ [ ] Agency [ ]Other (please state) NATURE OF ISSUES: ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. HOW DID THE REFERRAL SOURCE FIND OUT ABOUT SEDAS? ............................................................................................................................. ............................................................................................................................. SEDAS Staff Member (signature) ................................................................. Developed 15/1/08