You can contact us in confidence yourself or you can ask someone else to contact us for you.

**Office Closure during Christmas and New Year Holidays**
Please note that our Offices will be closed from 23 December 2017 for Christmas and will re-open on 2 January 2018. We will reply to all enquiries received during the Christmas break on our return in January.

Advocacy Referral and Request Form:

  • Please complete our Online Advocacy Referral & Request Form below
    [NOTE: Once completed the Confirmation message appears at the foot of the Form!]
  • Or alternatively, you can download a PDF hardcopy version here: AIB-Referral-Form (PDF, 66K)

Advocacy Referral and Request Form

Important You must reside in Barnet and be aged over 50 years.
Please complete the form below as fully as possible so we can understand your requirements and provide the best Advocacy Service for you.

Title:

First Name:

Surname:

Preferred Name:

Date of Birth (YYYY-MM-DD):

Age (in years):

Full Home Address:

Postcode:

Email:

Telephone:

Mobile:

Referred By:

Referrer's Name:

Referrer's Email:

Referrer's Contact Number:

Referral Source:

Self - How did you hear about AIB?Relative/FriendSocial ServicesGPPractitionerConsultantsMacmillan Services – please specifyLGBT servicesClinical Nurse SpecialistVoluntary OrganisationOther: Please Specify?

Other organisations involved:

Please list other Organisations involved? and how long since last contact?

Social Services referrals:

How many visits have been made to the client?

When was the most recent visit to the client?

Are there any forthcoming meetings planned?

Initial Referral Issues:

What are his/her/your advocacy needs (please tick appropriate, feel free to tick more than
one):

Advocacy under Care Act:
Needs assessmentsContinuing care assessmentsFinancial assessmentsSupport care planning

Future Care:
Advance Care PlanFuneral PlanningRegistering as an organ donorDiscussing DNARLasting Power of Attorney

Cancer Advocacy:
Support at appointments/consultationsTransport issues

Hospital Advocacy:
Care in hospitalDischarge procedureDischarge aftercare package

Accommodation Issues:
Housing TransferSale of propertyMaintenance and repairsTenancy IssuesTransitions

Financial Issues:
Financial AbuseLiaising with banks/utilitiesConsumer rights and compensationEquipment and adaptations

Other Advocacy Issues:
Blue badge and Freedom PassEquipment and adaptations

Health Background

Cancer: YesNo
Please state type:

Caring responsibilities: YesNo
Please specify:

Dementia: YesNo
Please specify:

Emotional: YesNo
Please specify:

Hearing impairment: YesNo
Please specify:

Learning difficulty including autism: YesNo
Please specify:

Long term health conditions: YesNo
Please specify:

Multiple impairments: YesNo
Please specify:

Physical impairment: YesNo
Please specify:

Registered disabled: YesNo

Visual impairment: YesNo
Please specify:

Other Health Issues: please state:

Further Important information

AWARENESS: Is the client aware that a referral has been made? YesNo

Further Background Notes for this Request for Advocacy?

Is there any challenging behaviour or health and safety risk?

Any other useful information:

Equal Opportunities Monitoring

We'd appreciate your help with monitoring, so that we can give the best possible service to all sections of Barnet’s community.

All information on this sheet will be treated as confidential and not kept with your file. Please tick the boxes that apply to you.

Gender:
MaleFemalePrefer not to say

Age:
25 or under26-3536-4546-5556-5960-6465-7576-8485+

How would you define your ethnicity? Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the appropriate box:

Asian or Asian British:
BangladeshiChineseIndianPakistaniOther Asian

Black or Black British:
AfricanCaribbeanOther Black

Mixed Background:
Asian and WhiteBlack African and WhiteBlack Caribbean and WhiteOther Mixed

White or White British:
BritishGreek CypriotTurkish CypriotIrishOther White

Other:
Other Ethnic Group

Do you consider yourself to be disabled?
YesNoPrefer not to say

What is your sexual orientation?
HeterosexualGay woman/lesbianGay manBisexualTransgenderPrefer not to sayOther

If other, please specify:

What is your religion or belief?
No religion or beliefBuddhistChristianHinduJewishMuslimSikhPrefer not to sayOther

If other, please specify:

Do you have caring responsibilities? If yes, please tick all that apply:
NonePrimary carer of a child/children (under 18)Primary carer of disabled child/childrenPrimary carer of disabled adult (18 and over)Primary carer of older personSecondary carer (another person carries out the main caring role)Prefer not to sayOther

Geographical Area?
N2N3N11N12N14N20NW4NW7NW9NW11BarnetNew BarnetEast BarnetEdgwareOther

If other, please specify: