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 officerCustody ManagerPolice, otherFamily memberPartnerLegal representativeClientCourt 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 crimeCourt support (Victim/Witness)Court support (Defendant)Police interview (Victim/Witness)Police interview (Suspect)Court (AVL Person in custody)Legal appointmentYouth CautionYouth 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 housingSupported accommodation i.e. group homeCrisis accommodation i.e. refugeIn custodyWith familyNo fixed address Has the person given their consent for this referral? * Yes No Is the person Aboriginal and/or Torres Strait Islander? * AboriginalTorres Strait IslanderAboriginal & Torres Strait IslanderNeither 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 disabilityBorderline intellectual functioningAutismAcquired brain injury, including foetal alcohol spectrum disorderDementiaNot sure Does the person have legal representation? * Yes No Unsure Who is the legal representative? Aboriginal Legal ServiceLegal Aid NSWChildren’s Legal Service (Legal Aid NSW)Private LawyerAbility Rights Centre, IDRS Additional information to support your referral, if required Submit
