Lamp Referral Form - Lamp Advocacy

Self Referral or Third Party

SELF-REFERRAL
THIRD PARTY REFERRAL

PLEASE NOTE THAT WE ARE UNABLE TO ADVOCATE FOR SOMEONE WITHOUT THEIR AGREEMENT AND PERMISSION. ONCE YOU PROVIDE THEIR DETAILS, WE WILL ATTEMPT TO MAKE CONTACT WITH THEM TO GET THIS AGREEMENT. IF THEY ARE UNABLE OR UNWILLING TO GIVE THEIR AGREEMENT, WE WILL BE UNABLE TO SUPPORT THEM.

Personal Details

Name *

First

Last

Email *

Preferred method of contact *

Phone *

Date of Birth *

Ethnicity *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Gender *

How did you hear about Lamp? *

How would you like us to help? *

Please tell us in more detail why you need our help *

In a few words, please explain what issues you are facing and what you would like to achieve with an advocate

Supporting Documents

Click or drag files to this area to upload. You can upload up to 10 files.

Anything you deem helpful in is supporting you. Eg. Doctors Letter, Appointment Dates

Custom Captcha *

9 * 10 =