Contact Us

Intake Form

Do you, or someone you know, have an issue that requires advocacy support? Please complete this intake form and our Intake Officer will be in contact with you in the next 2-3 business days. Please note that submitting this form does not guarantee that we can provide support for your issue. If your inquiry is urgent, please call 1800 250 292. For more information on our Advocacy Intake, Allocation and waitlist process, please follow this link.

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Does this inquiry relate to yourself or another person?

• Myself
• Another person

More questions will appear after this question is answered.

Have you received consent from this person to contact us and to provide their details? *

• Yes
• No

this phone Full

Your Name *

Your Organisation (if applicable)

Your Phone Number *

Your Email Address *

Your relationship to this person

Full name of the person this inquiry relates to *

First

Last

What town or suburb does this person live in? *

Your full name *

First

Last

What town or suburb do you live in? *

Residential address (optional)

Address Line 1

City

State / Province / Region

Postal Code

Your phone number *

Their phone number

Email

Your preferred method of contact

• Phone
• Text
• Email

Their preferred method of contact

• Phone
• Text
• Email

Date of birth

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Gender

• Male
• Female
• Non-binary
• Prefer not to say

What is their disability? *

What is your disability? *

Please provide a summary of your Advocacy issue

Please provide a summary of their Advocacy issue

Do you have any specific needs related to your disability that we should be aware of?

Do they have any specific needs related to their disability that we should be aware of?

Do you require an interpreter?

• Yes
• No

Do they require an interpreter?

• Yes
• No

What is your first language?

What is their first language?

How did you find out about RDAS? *

• Radio ad
• I am a previous client
• An agency/organisation told me about you
• Online search
• Other, e.g. friend or family member

Which agency/organisation told you about us?

Please specify

Do you have a nominated representative to act on your behalf?

• Yes
• No

Please provide their name, contact number or email address, and tell us how they know you.

Do you give consent for your representative to act on your behalf?

• Yes
• No

Are there any important dates we need to be aware of in relation to this support request?

• Yes
• No

Please provide details

Should we contact them directly, or contact you first? *

• Please contact me first
• Please contact them directly

Submit