Does the person know that you are contacting NAS on their behalf? (NAS is led by the person, and where possible requires their direct instruction to begin working with them.)
—Please choose an option—YesNo
Can the person speak to NAS directly rather than this enquiry form being completed on their behalf? —Please choose an option—YesNo
Has the person given their explicit consent to you for their personal information to be shared? —Please choose an option—YesNo
Date consent obtained:
By whom:
If no, is the enquiry necessary to protect vital interests of the person? —Please choose an option—YesNo
If no, is the enquiry necessary for public interest or official authority? —Please choose an option—YesNo
Name
Address
County
—Please choose an option—CarlowCavanClareCorkDonegalDublinGalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanOffalyRoscommonSligoTipperaryWaterfordWestmeathWexfordWicklow
What are the Advocacy Issues? (Please note NAS provides one to one representative advocacy for adults only (18+) and works on an issue specific basis. NAS do not offer long term social support or other services such as key working, social work or legal services).
What steps have you taken to support the person with these Issues?
(i.e. Friends and Family - name and contact details (Where relevant):
Any steps taken by significant others to support the person with these issues?
(name and contact details where relevant):
Please indicate if they are aware of the advocacy issues identified and what steps they have taken to support the person with these issues:
Please Select Nature of Person's Disability Intellectual DisabilityDementiaAutism Spectrum DisorderAcquired Brain InjuryMental HealthSensory DisabilityPhysical DisabilityOther (please state below)
Please Select Primary Means of Communication VerbalGestures / Facial Expressions / VocalisationsOther Spoken LanguageNo Obvious Means of CommunicationSign LanguageWords / Pictures – Picture BankOther (please state below)
Position/Relationship to person:
Telephone
E-mail
PLEASE USE THE SPACE BELOW TO ADD ANYTHING ELSE YOU FEEL IS OF IMPORTANCE (i.e. are there specific days of the week or times of the day when it is easier to contact the person to arrange a first visit, should the advocate contact the enquirer to arrange a first visit etc.)
Other Essential Information:
Has the person given permission for an Advocate to contact them? —Please choose an option—YesNo
Person’s contact details (if appropriate):
If person resides in a residential setting, is this enquiry being made following a HIQA inspection? —Please choose an option—YesNo
Please be aware that upon receipt of this enquiry the national advocacy service for people with disabilities is confidential, and therefore the national advocacy service for people with disabilities will only have further contact with you under the specific authority of the person or where necessary. Please note that completion of this form does not automatically result in an advocate being appointed for the person. This form is part of an enquiry process to determine whether or not NAS is the right service for the person.
I confirm that I have read and understood the NAS data protection notice
I confirm that I accept the terms as stated.
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