JAS Online Referral If the person needing support is in Police custody or requires support within the next 14 days call the JAS hotline 1300 665 908 JAS Online Referral Referrer Details Full Name * Organisation (if applicable) Address | Location * Email * Contact Telephone * Relationship to person being referred * Arresting officer Custody Manager Police, other Family member Partner Legal representative Client Court Officer Person with Cognitive Impairment’s Details Full Name * Alias/Other names Date of Birth * Gender * Male Female Indeterminate/Intersex/Unspecified Address * Contact Telephone * Location of support e.g. Downing Centre * Date of support * Time of support * What support is required? * Reporting a crime Court support (Victim/Witness) Court support (Defendant) Police interview (Victim/Witness) Police interview (Suspect) Court (AVL Person in custody) Legal appointment Youth Caution Youth Justice Conference Please list the offence(s)/charge(s) that relate to this referral & provide any relevant information relating to the circumstances of the offence/charge Alternative Contact Alternative Contact Name * Alternative Contact Telephone * Alternative contact relationship to PWCI * Person’s current living arrangements * Independent housing Supported accommodation i.e. group home Crisis accommodation i.e. refuge In custody With family No fixed address Has the person given their consent for this referral? * Yes No Is the person Aboriginal and/or Torres Strait Islander? * Aboriginal Torres Strait Islander Aboriginal & Torres Strait Islander Neither Aboriginal & Torres Strait Islander What is the person’s Culturally or Linguistically Diverse Background * Australian English Irish Scottish Chinese Italian Indian German Greek Vietnamese OtherOther Prefer not to say Languages spoken * English OtherOther What is the nature of the person’s cognitive impairment (if known) Intellectual disability Borderline intellectual functioning Autism Acquired brain injury, including foetal alcohol spectrum disorder Dementia Not sure Does the person have legal representation? * Yes No Unsure Who is the legal representative? Aboriginal Legal Service Legal Aid NSW Children’s Legal Service (Legal Aid NSW) Private Lawyer Ability Rights Centre, IDRS Additional information to support your referral, if required Submit If you are human, leave this field blank.