Sage Advocacy Referral Form

Referral Source*

SelfOther

Is the client consenting to this referral being made? (*Please only tick non-instructed advocacy if the client has been supported to understand why a referral is being made and why their information needs to be recorded, but is unable to give his/her consent.)*

YesNoNon-instructed advocacy*

Date of Referral*

DayMonthYear

Date of Referral - old version

Client Name*

First NameLast Name

Current Address*

Street Address

Street Address Line 2

City

Eircode

Previous Address (if different)

Street Address

Street Address Line 2

City

Eircode

Date of Birth*

DayMonthYear

Date of Birth - old version

Phone Number*

Area CodePhone Number

Email

Reason for referral – Presenting Issue(s) (Please tick where applicable)*

Why do you (or the person you are referring) require an advocate*

What action (if any) has been taken in relation to the presenting issues?*

Other People who are supporting you (or the person you are referring):*

Referrer Name

First NameLast Name

Organisation

Address

Street Address

Street Address Line 2

City

Eircode

Relationship with Client

Phone Number

Area CodePhone Number

Email

example@example.com

I, the Referrer, consent to Sage collecting, using and storing my personal information to provide the service I have requested*

YesNo

Signature*

Please verify that you are human*

Personal data is processed by Sage Advocacy based on the individual’s explicit consent. Where the individual is unable to give consent, personal data is processed by Sage Advocacy based on the vital interests of the individual. Sage Advocacy complies with the Data Protection Acts, 1988-2018 (including GDPR). All information provided is safeguarded securely, safely, and privately. Sound recordings of any meeting whether involving third parties or otherwise, without permission of all participants will be regarded as a data breach. The information may be retained for up to 10 years, and may be anonymised for systemic case research and statistical purposes. We do not share any service user information with third parties without explicit consent, unless we are required to do so by law or to protect the service user or another individual from serious harm. There are rights available to data subjects, including the right to withdraw consent. For further information see http://ec.europa.eu/justice/data-protection/reform/files/regulation_oj_en.pdf

Client Information

Referral Details

Details of person making referral (if different from above)