Health Complaints Advocacy Referral Form

Our Health Complaints Advocacy service is for anyone in Leeds who needs help to make a complaint about a local NHS service. This is free to use and you can self-refer. To make a referral, please complete the form below.

Health Complaints Advocacy Referral

Your email (required)

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

How did you hear about this service? (required)

1. Details of the person requiring advocacy

Your Name (required)

Current Address/ward/unit

Postcode

Home Address (where you usually live)

Postcode

Preferred contact method

Current Phone Number

Can we leave a message?

YesNo

Email address

2. Complaint Details

2. Is the person making the complaint the patient?
YesNo

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

If No, please tell us why

Please provide the patient's name

Please provide the patient's date of birth

Organisation you’re complaining about

Other - please state below:

What is the reason you are complaining?

Other - please state below:

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

4. Referrer details (only fill this in if you are not the person who requires advocacy)

Name

Job Title

Employer

Phone number

Place of work, including address

5. 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

6. Other relevant information about the person requiring advocacy

If you / the client has any support needs e.g. communication, please write them down in the box below

What is the person's first language?

Are there any additional communication or other needs not already mentioned e.g. needing advance notice of meeting dates/times?

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.

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

Gender

Other: Please tell us

Is their gender the one they were assigned at birth?
YesNoDon't KnowPrefer not to say

Ethnicity

Other: Please tell us

Religion

Other: Please tell us

Sexuality

Other: Please tell us

Disability – for monitoring and equal opportunity purposes, please let us know if the client has any of the following disabilities/impairments by ticking the relevant boxes
Acquired brain injuryAutistic Spectrum ConditionBlind/partially sightedCarerCognitive impairmentDeafDementiaLearning disabilityLong-term health conditionMental health needsOlder person (frailty)Physical condition/illness

Is the client disabled in any other way not listed above? If so, please write in this box.

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.

Word Referral Form

If you are having issues with our online referral form, we have a version of it in Microsoft Word. To make a referral this way, please download the document by clicking on the button below, complete it and email it to [email protected]. Please also get in touch if you have any questions about the referral form.

Health Complaints Advocacy Referral Form – Word Doc