Adult Social Care Involvement Network

About You

Thank you for your interest in helping us to make social care services better.

Please fill in this form to tell us about yourself and we will contact you with opportunities to get involved in activities that match your interests. You can take part as little or often as you feel able, and you can say “No” at any time.

We will treat personal information that you share with us as confidential unless you say otherwise, or unless you or someone else is at risk of harm.

If you have any questions, or need help to fill in the form, please contact us by telephone on 020 7527 8157 or by email to ..

1. Your contact details:
Your title (e.g. Mr, Mrs, Ms)______
Your name: ______
Your address: ______
______
Your email address: ______
Your telephone number: ______
2. Your areas of interest or lived experience: please tick all that apply
[ ] Physical disabilities
[ ] Learning disabilities
[ ] Mental health
[ ] Older people
[ ] Dementia
[ ] Deaf/hard of hearing
[ ] Visual impairment
[ ] Drug and alcohol misuse
[ ] Long term conditions (eg diabetes)
[ ] Life limiting conditions (eg COPD) / [ ] Carers and Family carers
[ ] Homelessness
[ ] Services for men / women (circle)
[ ] Services for people who are Lesbian, Gay, Bisexual, Transgender (LGBT)
[ ] Services for Black and Minority Ethnic (BME) communities or Faith groups
[ ] Safeguarding
[ ] Personal budgets
[ ] Peer support/led opportunities
[ ] Other (please give details) ______
______
3. Activities you would like to take part in (see ASCIN leaflet for more information):
please tick all that apply; there is no obligation to commit to any activity
[ ] Come to events
[ ] Take part in meetings
[ ] Join a readers groups (by post or email)
[ ] Take part in focus groups or surveys(this could be in person, online, by email, post or telephone) / [ ] Find out how services are doing (e.g. peer research and mystery shopping)
[ ] Train staff or people who use services
[ ] Take part in staff recruitment
[ ] Help us to shape new services
[ ] Service user/carer led ideas and projects
[ ] Sign up to our email distribution list
[ ] Other (please give details):______
______
4. Please tell us about any health and social care services you have used recently, or any related groups or organisations that you are a member of.
______
______
______
5. Do you have any access or support requirements or a health condition that might affect your involvement? [ ] Yes [ ] No
If Yes, we will fill in an Access questionnaire with you so that we can provide the right support for you to get involved.
6. Do you have any dietary requirements?[ ] Yes [ ] No
If yes, please give details ______
______
7. Is there anything else you’d like to tell us?
e.g. particular days/times that are best for you, or related skills or knowledge.
______
______
______

Thank you!

Please return completed forms to the User and Carer Initiatives Team, either by email to or by post to User and Carer Initiatives, Islington Council, Adult Social Services, 7 Newington Barrow Way, London, N7 7EP.