Maternity and Neonatal Independent Senior Advocacy Referral

Maternity and Neonatal Independent Advocacy Referral

I'm making a referral for:

Myself

On behalf of someone else

My details

Name

First Name

Last Name

Phone Number

Alternative Phone Number

Email Address

Address

Address 1

City

Postal Code

County

Your relationship to the person being referred?

What support are you seeking?

Support eligibility

After 24 weeks of pregnancy, your baby died before or during birth

Your baby died within 28 days of being born

Your baby has a brain injury or a brain injury is suspected

You were cared for on a critical or intensive care unit and this was unexpected

You had an unexpected or unplanned hysterectomy (removal of your womb) within 6 weeks of giving birth

Your baby’s mother or birthing person has died

None of the above, I would like to discuss my query with an Advocate

Further details about you

How do you communicate?

Verbally

Verbally, but with difficulty / through communication equipment

In a language other than English

Not in a way we can understand

Which language(s) do you speak?

Please enter the language(s) in the field

Specify how you communicate

Please specify your communication method in the field

Specify your nationality

Please enter your nationality in the field

If yes, please leave further details below

Is there anything else you feel that is important we are aware of?

How did you hear about this service?

Please select an option from the list

Through the internet

By word-of-mouth

From another organisation

Message

Declaration for data protection

Because of the Data Protection Act, a signature is needed to say that you agree to the Advocacy Hub and the Advocacy Service Provider securely holding and sharing (as appropriate) personal information (including the information on this form), on a computer and in a filing system. It is the policy of the Advocacy Hub and the Advocacy Service Provider that all personal data will be held in accordance with the principles and requirements of Data Protection and other relevant legislation, and that procedures will be put in place to ensure the fair processing of data relating to individuals. The Advocacy Hub and Advocacy Service are confidential service; you can request further information on confidentiality from the Advocacy Hub or the Advocacy Service Provider.

I agree to that the Advocacy Hub and the Advocacy Service Provider can securely hold and put on computer and in a filing system and share (as appropriate), the information on this form.

I would like the Advocate to do this work. The Advocacy Hub and the allocated Advocacy Provider can keep and put on computer and in a filing system and can share (as appropriate), the information on this form provided to do the work. I am providing this information and asking for this referral in the clients best interests.

Agreement

I agree to the above declaration

Maternity and Neonatal Independent Advocacy Referral

My details

Details of person being referred

Further details about the person you are referring

What support are you seeking?

Further details about you

Declaration for data protection