DFS - Clients - Advocacy Form

Choose your nearest DFS clinic *

I,

Client Name *

of

Client Address (Street) *

City *

Postcode *

State *

give

Case Manager / Practitioner Name *

and other personnel of Direct Focus Solutions involved in the management and/or provision of services to me permission to:

Advocate on behalf of myselfHave the individual(s) listed below act as advocate(s) on my behalf

1.

2.

3.

4.

I understand that by signing this form that I have the right to:

Client Name *

Client Signature *

Draw signature|Type signatureClear

Date *