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Advocacy Referral Form

About the Person
A / Mr/Mrs/Ms/Dr/Other / Name
Preferred Name
B / Current Place of Residence (at date of referral)
C / Accommodation Type
(e.g. Hospital, Own Home, Residential Home)
D / Telephone Number / Date of Birth
Email Address
E / Please describe the specific reasons you are requesting advocacy support
F / Personal Contacts(including in an Emergency)
G / Eligibility Checklist
Person must be (delete as appropriate)
Currently resident in Doncaster Borough Yes / No
and
Over 18 years old Yes / No
and
Has a social or health care service issue Yes / No
And at least one of the following:
  1. An older person Yes / No
  2. Has a physical disability Yes / No
  3. Has a sensory disability Yes / No
  4. Has a learning disability Yes / No
  5. Has mental health issues Yes / No
  6. Is an adult carer Yes / No
  7. A person in transition into adult services Yes / No
  8. A person with social care needs Yes / No

Support Needs and Risks
H / Support Needs: Please detail any support needs the advocate needs to be aware of to provide advocacy (e.g. any long term condition, impairment, language or preferred communication methods):
I / Risks: Please detail any information needed to ensure the safety of the advocate and the referred person during the advocacy:
Key People
J / Referred byOther / Self / Professional / Other
If you are making a referral on behalf of another person please provide your details / Print Name
Position or Relationship to person
Organisation
Tel No
Mobile No
Fax No
Email
K / If you are making a referral on behalf of another person, is the person aware of the referral? / Yes No
If no, please outline reasons for this
L / Involved professionals & contact details
(if relevant)
M / Any other relevant information
N / Signature (Referrer) / Date
Time

Post:VoiceAbility Doncaster

Doncaster Advocacy Services

Rear of Carcroft Club, 6 Chestnut Ave, Carcroft, Doncaster, DN6 8AG

Email:

Fax: 01302 319052

Do you consider yourself
Male / Transgender / Female / Prefer not to say
How would you describe your ethnic origin or background?
White / English / Welsh / Scottish / Northern Irish / British
Irish
Gypsy or Irish Traveller
Any other White background(please state)
Mixed and Multiple Ethnic Groups / White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple Ethnic background (please state)
Asian / Asian British / Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
Black / African/ Caribbean / Black British / African
Caribbean
Any other Black / African / Caribbean background (please state)
Other Ethnic Group / Arab
Any other ethnic group (please state)
Prefer not to say
How would you describe your sexuality?
Heterosexual / Homosexual/Gay/Lesbian / Bi-sexual / Prefer not to say
How would you describe your religious beliefs?
No Religion / Jewish
Christian / Muslim
Buddhist / Sikh
Hindu / Any other religion please specify
Prefer not to say
What is your primary need for support?
A Learning Disability / Mental Ill Health
A Physical Disability / A Sensory Impairment
Dementia / Autism
An Acquired Brain Injury / Physical Ill Health
Profound and Multiple Learning Disabilities / Other (Please specify)
Prefer not to Say
Please indicate any other areas of support you have (Tick all that apply)
A Learning Disability / Mental Ill Health
A Physical Disability / A Sensory Impairment
Dementia / Autism
An Acquired Brain Injury / Physical Ill Health
Prefer not to say / Other (Please specify)

Advocacy Referral Form – Doncaster – Nov 2017

VoiceAbility Registered Charity 1076630 Limited Company 3798884