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

Advocacy Request Form:

  • Please complete our Online Advocacy request Form below
    [NOTE: Once completed the Confirmation message appears at the foot of the Form!]
  • Or you can download a PDF paper version here: AIB Advocacy Request Form (PDF, 180K)

Advocacy 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 (if known):

Referred By:

Referrer's Name:

Referrer's Email:

Referrer's Contact Number:

Referral Source:

Self-referred (How did you hear about AIB? please specify below)Relative/FriendSocial ServicesGPPractitionerConsultantsLGBT servicesClinical Nurse SpecialistOther Voluntary OrganisationHelpline (please specify below)Other (please specify below)

Client Details:

MrMrsMissMsOther (please specify below)

Forename:

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):

Home Address:

Postcode:

Email:

Telephone:

Mobile:

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?

Reasons For Request:

PLEASE EXPLAIN THE ISSUE(S) YOU REQUIRE ADVOCACY WITH:

(Example – Housing Transfer, Needs Assessment, Care Review, Hospital Discharge. Please include the Name of the Client’s Social Worker/Housing Office/Housing Association if relevant.

Health Background

Please specify if you have any of the following...

Any long-term conditions:

Physical impairment (non-sensory/Age Related Frailty):

Visual impairment:

Hearing impairment:

Learning difficulty including autism:

Cognitive impairment:

Mental Health:

Multiple impairments (please state):

Does the client have caring responsibilities for a dependent or loved one(s)?

Registered disabled: YesNo

Does the person live alone?

Other Health Issues (please state):

Further Important information

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

Are there any risk factors that the Advocate should be aware of? (i.e. challenging behaviour)

Any other useful information:

Consent

CLIENT: I (the client) consent to Advocacy in Barnet holding my personal data and I have read the Privacy Policy as per GDPR effective 25 May 2018.REFERRER: I (the referrer) confirm I give consent to sharing my personal data and also the client has consented to my sharing their personal data with you and agree that their data will be held by Advocacy in Barnet for the purposes of providing advocacy support.

(Please read our Privacy Policy).