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

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, 210K)

Advocacy Referral and Request Form

Important: 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.

Date of Request:
*

[* in older browsers where the date selector is not displayed when you hover-over the date box, please enter the date in the format: YYYY-MM-DD]

Case Number:

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 specify below)LGBT servicesClinical Nurse SpecialistVoluntary OrganisationHelpline (please specify below)Other (please specify below)

Client Details:

Title:

First Name:

Surname:

Preferred Name:

Date of Birth:
*

[* in older browsers where the date selector is not displayed when you hover-over the date box, please enter the date in the format: YYYY-MM-DD]

Age (in years):

Full Home Address:

Postcode:

Email:

Telephone:

Mobile:

Other organisations involved:

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

Housing Association?

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 planningCare & support review

Future Care:
Advance Care PlanFuneral PlanningRegistering as an organ donorDiscussing DNAR

Accommodation Issues:
Housing TransferSale of propertyMaintenance and repairsTenancy Issues

Hospital Advocacy:
TransitionsCare in hospitalDischarge procedureDischarge aftercare package

Cancer Advocacy:
Support at appointments/consultations

Financial Issues:
Financial AbuseLiaising with banks/utilitiesEquipment and adaptations

Other Advocacy Issues: please specify below -

Health Background

Any long-term conditions, e.g. Parkinson’s Disease, Multiple Sclerosis, Chronic obstructive pulmonary disease (COPD), Diabetes, arthritis, etc - please specify:

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

Is there any challenging behaviour or health and safety risk?

Any other useful information:

I (the Client) give consent to Advocacy In Barnet holding my data and have read the Advocacy In Barnet Privacy Policy. (See: Privacy Policy).