Part 1: Health Complaints Advocacy Referral

Your email (required)

How did you hear about this service? (required)
---CarerEvent/Information stallFamily/friendsPrevious ClientI've referred to the advocacy service beforeI've used the advocacy service in the pastTwitter/FacebookWebsite (Advonet)Website (other)Word of mouth

Date of referral (DD/MM/YYYY) (required)

1. Are you the patient?
YesNo

If you are the patient's representative, have they given you consent to complain on their behalf?
YesNo

If No, please tell us why they have not given you consent

2. Organisation you’re complaining about
---Leeds Teaching Hospitals NHS Trust (LTHT)Leeds and York Partnership NHS Foundation Trust (LYPFT)Leeds Community Healthcare NHS Trust (LCHT)NHS Leeds Clinical Commissioning Group (CCG)Other

Other - please state below:

What is the reason you are complaining? ---Attitude of StaffCare and TreatmentDelayed or MisdiagnosisDelays in TreatmentLack of, or wrong informationNegligenceOther

Other - please state below:

Part 2: Referral Information

3. Client Details (person requiring advocacy)

Your Name (required)

Home Address (where you usually live)

Postcode

Current Address/ward/unit (if different from your usual address)

Postcode

Preferred contact method ---Contact a person who is helping meEmailLandline telephoneMobile phoneSkype/video callText

Enter your contact details here, e.g. email, mobile number or the contact details of the person who is helping you. (If you give us their contact details we will take this as consent that we can contact them to discuss your issue)

Current Phone Number

Can we leave a message?

YesNo

Your Date of Birth - we ask for this information as some of our services are for specific ages (DD/MM/YYYY)

The following information is collected to help us create equal opportunities for individual’s resident within our local communities. We use this information anonymously to identify if the diversity of the people accessing our services fully reflects the communities we serve. If you prefer not to answer please select that option.

Gender
---MaleFemaleTransNon-binaryPerson referring doesn’t knowOtherPrefer not to say

Other: Please tell us

Ethnicity
---Asian/Asian British (Bangladeshi)Asian/Asian British (Chinese)Asian/Asian British (Indian)Asian/Asian British (Pakistani)Asian/Asian British (Other)Black/Black British (African)Black/Black British (Caribbean)Black/Black British (Other)Mixed: White/AsianMixed: White/Black AfricanMixed: White/Black CaribbeanMixed: OtherWhite (British)White (Irish)White (Other)OtherDon't knowPerson referring doesn't knowPrefer not to say

Other: Please tell us

Religion
---BuddhistChristianHinduJewishMuslimSikhNo beliefNo religionOtherPerson referring doesn't knowPrefer not to say

Other: Please tell us

Sexuality
---HeterosexualLesbianGayBisexualPansexualOtherPerson referring doesn't knowPrefer not to say

Other: Please tell us

Has the person you are referring given you consent to refer?

YesNoNot yetPerson lacks capacity to consent

Please say below why you cannot obtain consent

4. Reason for advocacy referral? (Please include a summary of the advocacy issue/decision being made, upcoming meeting dates, deadlines, priority areas etc.)

5. Referrer details

Name

Role/Job Title

Employer
---AdvonetLeeds City CouncilLeeds Community Healthcare NHS TrustLeeds Teaching Hospitals TrustLeeds and York Partnership Foundation TrustVoluntary OrganisationOther

Place of work, including address

Phone number

Mobile number

Email address

Secure email

6. Risk Issues

Are there any current Risk Issues we need to be aware of? If Yes, please provide details below (e.g. restrictions etc.)

YesNo

7. Other relevant information about the person requiring advocacy. Please select all that apply.

Support Needs
---Acquired brain injuryAutistic Spectrum ConditionBlind/partially sightedCarerCognitive impairmentDeafDementiaLearning disabilityLong-term health conditionMental health needsOlder person (frailty)Physical condition/illness

Additional Support Needs
---Acquired brain injuryAutistic Spectrum ConditionBlind/partially sightedCarerCognitive impairmentDeafDementiaLearning disabilityLong-term health conditionMental health needsOlder person (frailty)Physical condition/illness

Is the person a carer?
---YesNoDon't know

How does the person communicate?
---British Sign Language (BSL)Cue CardsFirst language (please state in 'Any other relevant information' box)GesturesMakatonVerballyWritingOther

What is the person's first language?

Any other relevant information?

Glossary of Terms:

Non-binary refers to individuals who don’t see themselves as either male or female. Individuals identifying as non-binary may ask you to use gender neutral pronouns such as they/their rather than he/she. Please do not ask non-binary individuals the sex or gender assigned to them at birth as this is irrelevant.

Trans male/female refers to individuals who are transitioning to the gender they identify with.

Pansexual refers to individuals who are romantically, emotionally, sexually attracted to people regardless of their sex and gender identity.