Lamplight API response

First name

Last name

Address 1

Address 2

Address 3

Address 4

Address 5

Postcode

Email address

Mobile phone

Phone number

Sometimes we will share information with you about our services. We won't share with other organisations. How do you prefer us to contact you - tick all that apply.

By post

By email

By mobile

By text message

No contact

Other information

Any other relevent addresses

Any other phone numbers

What pronouns - how should we address you? (She/her, He/him, They/them, I prefer not to say)

Date of birth

If date of birth not completed

Preferred languages

Will an interpreter be required

Do you/they have any communication needs?

Where did you hear about Connected Voice Advocacy

Does the person have the mental capacity (understand, retain, consider, communicate and recall) to instruct an advocate on this subject?

Are there any urgent meetings planned?

Please give details of any urgent meetings

Are you/they at risk of harm or abuse (safeguarding concerns)

Please detail any safeguarding issues

Select GP/Doctor

GP/Doctor first name

GP/Doctor last name

Medical Consultant (if any)

Medical Consultant's first name

Medical Consultants last name

Medical Consultants phone number

Medical Consultants email

Social worker / Care coordinator

Social care worker / Care coordinator first name

Social care worker / Care coordinator last name

Social care worker / Care coordinator phone

Social care worker / Care coordinator email

Tell us more about the person wanting advocacy. This is optional and anything you tell us will help us understand our community so we can meet needs more effectively.

Gender

Is your/their gender at birth, the same as now?

Disability details

Sexuality

Asexual

Bisexual

Gay man

Heterosexual/straight

Lesbian

Prefer not to say

Queer

Questioning

In another way (please describe below)

Sexuality details

Ethnic origin

Ethnic origin, further details if requested

Country of origin / cultural identity

Religion/belief

By signing here I agree that Connected Voice can store this information that I have shared about me. I know it will be stored securely and I can ask to see it anytime.

Please write name here to agree to this.

Please check that you have completed all necessary fields and provided ALL necessary information.

If you are completing this form for yourself complete this box below and then scroll down to "submit"

Details of referral

Do we have consent to contact?

If you are completing on behalf of someone else

First name

Last name

Job title

Organisation

Referrer address

Referrer postcode

Referrer telephone

Referrer mobile number

Referrer email

Referrer relationship to person being referred

Risk information

No known risk

Risk of harm due to medication/medical conditionRisk of deliberate self-harm

Risk of suicideRisk of severe self-neglect

Risk of domestic violence/abuseRisk of adult abuse

Risk of violence/harm to othersRisk to a child

Risk to staffRisk of exploitation

Risk of radicalisation

Risk information details

Are you making this referral about yourself, or for someone else?

If making the referal for someone else, do they consent to the referral?

If the person lacks mental capacity to accept/decline advocacy support, please confirm that you are referring in their best interests (it would be good practice to inform the person of the referral where possible)