Intake Form -RIA FINAL

Where are you located? *

Please be informed that, due to your location, Rights in Action cannot assist with your situation.

RIA Service Coverage

RIA covers 40% of Queensland; however, some areas have limited coverage due to funding and the nature of our services.

Eligibility

To qualify for our services, you must be located in Queensland (QLD) and fall under our service region.

If You Made a Mistake

Please refresh this page and submit it using the correct region.

If You Are Outside Our Service Region

We can provide alternative options and places where you can seek assistance.

Additional Assistance

If you're still exploring support options and haven’t yet found what you’re looking for, don’t worry, you’re not alone, and help is out there.

We encourage you to check out Ask Izzy, a helpful online resource that can guide you to a wide range of community services that may be just right for your needs.

Visit Ask Izzy here . It’s designed to make navigating support easier, and it's available anytime you need it. You’ve taken a great step by reaching out. Keep going, you’re doing well.

Do you, or the person you are referring on behalf of, have a disability or mental health condition? *Example: You might be referring yourself because of a chronic condition, or on behalf of someone experiencing ongoing mental health difficulties. This could include mobility challenges, neurodiversity, or emotional well-being concerns that impact daily life. Some people have a formal diagnosis, while others may still require support without one; both are completely valid.

Thank you for reaching out

We genuinely appreciate you taking the time to connect with us.

At Rights In Action, our advocacy services are designed to support individuals living with disabilities. As well as assisting individuals experiencing Mental Health challenges, whether formally diagnosed or not.

While your current needs may fall outside the scope of our direct services, we remain committed to helping however we can.

If you're seeking guidance, we're more than happy to connect you with other trusted services or community resources that may be better equipped to support your situation.

Please don’t hesitate to reach out at 1800 887 688 if we can help point you in the right direction. we're here for you.

Are you seeking advoacy support for yourself, or on behalf of someone else? *You may be filling out this referral for yourself, or you might be helping someone else access support, such as a friend, family member, partner, carer, support worker, or a member of your community. In many cases, people act as a support person or advocate to assist someone they care about in getting the right help. If you are referring a child under 18, please note that the referral must be made by a parent or legal guardian. If that’s you, we’ll ask for your details in the next step so we can ensure everything is properly recorded.

Is this person under 18 years old? *

As the person is under 18 years old, we require the parents or legal guardians information below. If you are the legal guardian please choose "other" as the relationship.

Parent's First Name *

Parent's Last Name *

Parent's Date Of Birth?

Relationship? *

Please describe your relationship *

Parent's best email

Parent's best contact number? *

Parent's Address *

Street address *

City *

State *

Postcode *

As you have indicated that you're completing this form for someone else. That means you're what's called a "Referrer." Please fill out YOUR information below.

Referrer's First Name *

Referrer's Last Name *

Referrer's best contact number *

The Relationship of the Referrer? *

Referrer's Email address *

Has the person being referred given permission for the referral? *RIA is a consent only service. You will need your clients consent to proceed. Please note this also includes any future correspondence.

Please answer the following questions on behalf of the client, i.e. the person with a disability and/or mental health condition requiring advocacy support.

Client's First Name *

Client's Last Name *

Gender *

Do you identify as LGBTQIA+? *

Date of birth *

What is the preferred phone number for us to use when reaching out regarding this referral? *We’ll only use this number for necessary communication about advocacy support. If contact isn’t possible, we won’t be able to move forward with your request.

Email Address *

Residential address *

Street address *

City *

State *

Postcode *

Note to Clients and Referrers:

The next few questions help us collect information required by the program and funding requirements. Your responses help us plan services, improve support, and meet reporting needs. Please choose the option from each dropdown that best describes your situation. We’ve kept it straightforward to make it as quick and stress-free as possible.

What is your primary disability? *

Do you have a secondary disability? *

Are you an NDIS participant? *

What country were you born in? *

Do you identify as culturally and/or linguistically diverse? *

Do you require an interpreter? *

Other, Please list here

Do you believe you are, or have been, at risk of domestic/family violence? *Domestic or family violence can take many forms—not just physical. It may also involve actions that seek to control, intimidate, or hurt a partner or family member in other ways. You will not be asked to provide evidence or details, unless you wish to do so.

Do you identify as Aboriginal or Torres Strait Islander? *

Do you believe you are, or have been, at risk of homelessness? *Being homeless or at risk of homelessness means not having a safe, stable place to live. It can include sleeping rough, staying in temporary housing, or living in unsafe or unsuitable conditions.

Do you believe you are, or have been, at risk of financial disadvantage? *Financial disadvantage—or being at risk—means struggling to afford everyday essentials like housing, food, or healthcare due to low income or unexpected life changes.

Is there something specific you’d like support with through Rights in Action, or a particular issue you’d like help with? *Please select the area that best matches your current need from the dropdown menu—this might include housing, employment, NDIS, healthcare, education, QCAT, or Queensland Health (QH). Choosing the most relevant option helps us understand how to assist you effectively.

Could you please describe your disability or condition, and share how it affects your day-to-day life, including any challenges, barriers, or support needs you may have? *This might include the type of disability, diagnosed or undiagnosed conditions, and how it impacts things like mobility, communication, mental health, or access to services. Anything you feel comfortable sharing will help us understand how best to support you.

Example:
You can tell us about your disability or condition in your own words. This might include physical conditions, mental health, learning difficulties, or long-term illnesses.
You can share:
- What is your main condition (if you have one)?
- If there are any other health issues or challenges.
- How does it affect your daily life, for example, getting around, learning, remembering things, talking to people, or doing tasks at home or work?

You don’t need to use medical words — just explain what it’s like for you. Whatever you’re comfortable sharing will help us understand how to support you better.

Briefly describe the issue or challenge you’re needing help with. *Please tell us a little about the issue or concern you’re seeking support for. This might include what’s happening, when it started, and any key details you think are important. You’re welcome to share as much or as little as you feel comfortable — everything you tell us helps us understand how to best support you.

Have you taken any steps so far to try and resolve this issue, or sought help or support from someone else? *Whether you’ve reached out to any services or support people, tried to solve the issue on your own, contacted any organisations, or made any complaints. It’s also helpful to include if you’ve faced delays, barriers, or if you’re unsure what to do next. Even small actions, like looking online or attending an appointment, can be useful for us to understand where things are at.

What outcome are you hoping to achieve through our advocacy support? *You might reflect on what a good or fair result would look like for you, such as feeling heard, having a service issue resolved, accessing something important, or receiving clearer communication or support in navigating a process. Sharing this helps us understand what matters most to you, so we can advocate in the right direction.

What Type Of NDIS Issue? *

Have you lodged the ART application? *Disclaimer: You only have 28 days from date to make an application to ART.

Have you received a listing notice for a case conference? *

Have you advised this to the service provider? *

Have you reported this to NDIA/ Support coordinator? *

Have you reported this to NDIA/Plan manager/Support coordinator? *

Are you seeking assistance to make a complaint? *

Has a complaint been made and are you unhappy with the resolution? *

Are you seeking advice to make a complaint? *

Please advise what barriers you are experiencing to sourcing supports at the moment *

Have you received an outcome yet? *

Has an internal review been lodged? *

Do you have an NDIS support coordinator? *

What Type of Finance Issue? *

Have you applied for DSP? *

Have you applied for an internal review? *

When did you get the outcome letter? *

Are you currently receiving DSP? *

Does the client have a QCAT-appointed financial administrator? *

Is there an upcoming QCAT review date/ a pending application? *

Has an application been made to Queensland Victims Assist? *

Have you applied for the financial assistance? *

Is the Financial administer QCAT appointed or an EPOA? *

Are you seeking Education? *

And are you seeking assistance to make a complaint? *

What Type Of Employment Issue? *

Do you need assistance with understanding the process of making a WorkCover claim? *

Do you need assistance making a complaint to your employer? *

Do you need assistance with understanding the process/ making a fair work complaint? *

What Type Of Abuse/Neglect Issue? *

Are you seeking to challenge or change any restrictive practices currently in place? *

Have you experienced any restrictive practices in your care or support? *

Do you need advice on your rights regarding restrictive practices? *

Are you currently receiving any type of compensation or any type of community-funded support? *

Do you need assistance with making a complaint regarding abuse/neglect? *

Do you need assistance/advice in reporting an instance of abuse or neglect to relevant authorities? *

What Type Of Housing Issue? *

Are you at risk of losing your tenancy? *

Have submitted a Department of Housing application? *

Are you seeking assistance for a Department of Housing application? *

Do you have concerns related to Unsafe environment? *

Please understand that the support we can provide in this space may be limited, we will provide advice/assistance where possible. Please describe *

Do you feel you have been evicted unfairly? *

Are you contesting this eviction at QCAT? *

Have you received any advice on this from QSTARS? *

Have you contacted any housing services about this? *

Please explain who you have contacted here *

Are you at risk of losing your NDIS tenancy? *

Do you have tenancy-related grievances? *

What Type Of Education Issue? *

Have you made a complaint to the school/ education provider? *

Do you need assistance/advice to do this? *

Have you / your child been unfairly suspended or expelled? *

Do you have concerns that the educational provider is not making reasonable adjustments with respect to you disability ? *

Do you need advice on making a complaint? *

Do you need assistance in drafting a complaint? *

Do you need advice regarding an upcoming Mental Health Review Tribunal? *

Do you need a support person at the Mental Health Review Tribunal hearing ? *

Do you need assistance to draft a self-report? *

Are you appealing your treatment order at the Mental Health Court? *

Do you have concerns that a child is being neglected? *

Is the child under any child protection order? *

Do you believe that Child Safety is neglecting their obligations to a child in their care? *

What Type Of Decision-Making Concerns? *

Do you have an upcoming QCAT review scheduled? *

Do you want support to review your QCAT order? *

Do you need advice regarding Enduring Power of Attorney? *

Do you need assistance with supported decision-making? *

Do you think your decision-making is not acting in your best interest? *

Do you have legal representation? *

Do you require support to submit a Legal aid application? *

Do you require a referral to a legal service for advice? *

Do you require a support person to attend a legal advice appointment? *

Is this situation time sensitive? *

Will this situation become significantly worse in the next 48 hours? *

Please detail any known risks to RIA staff associated with engaging with client? *

Do you have a QCAT Appointed Adult Guardian or Financial Administrator? *

Decision Makers First Name? *

Decision Makers Last Name? *

Decision Makers Phone Number? *

Decision Makers Email Address? *

Does the Person with a disability consent to Rights in Action contacting them OR the referrer to provide follow up and assessment? *RIA is a consent only service. You will need your clients consent to proceed. Please note, this also includes any future correspondence.

Do you consent to provide relevant documents/evidence to Rights in Action as required? *If no, please note that providing documents is highly recommended for the best outcomes.

If known, please provide the best day and time between 9:00 am and 4:30 pm to contact the person? *

Save and Complete Later