Autism Care Navigator

Step 1 of 6

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About you

Name

First Last

Phone

Mobile

Your location

Street

City or town

Post code

Borough*

Is your GP based in Brent?

Yes

Your demographic information

Birthdate

DD slash MM slash YYYY

Gender

Gender: self-describe

Ethnic group

Ethnic group: self-describe

Sexual orientation

Sexual orientation: self-describe

Religion

Religion: self-describe

Disabilities

Learning disability

Mental health issue

Physical disability

Sensory impairment

Acquired brain injury

Dementia

Autism

Self describe

Disability: self-describe

Your communication needs and preferences

Language spoken

English

Arabic

Turkish

Bengali

Cantonese

Spanish

French

Italian

Mandarin

Polish

Gujarati

Hebrew

Urdu

Vietnamese

German

Yiddish

Portuguese

Persian/Farsi

Punjabi

Somali

Hindi

Romanian

Other

Communication support needed

Please use this space to let us know any communication support needed or communication professional required.

Preferred contact method

Preferred information format

Are you making this referral for yourself or on behalf of someone else?*

If you are completing this form on behalf of someone else, do you have consent?*

Contact details

If you are completing this form on behalf of someone else, please enter both sets of contact details here:

Services you use if any

1. Name of service

2. Name of service

3. Name of service

Service details

Please tell us about the services you use

Health conditions

Please tell us about your health conditions and how you manage them (optional)

Tell us how we can help

Additional information

Please tell us anything else you would like to share with us that will help us to support you

What support would you like

Email information about the care navigator service

Someone to phone me about the care navigation service

How else would you like to get involved?

Health awareness sessions

Sharing experiences/stories

Involvement in user group

If you need help or have questions about any aspects of the Autism Care Navigator process, please contact us:

Phone: 02081061477
Email: carenavigator@advocacyproject.org.uk

Permission for us to use this data

Please check the box if you understand that by submitting this personal information you are consenting to The Advocacy Project holding and using it in accordance with our privacy policy.

Please note we may share this referral information with one of our partner organisations if they are delivering the service you need. We will always check with you before sharing the information with the partner organisations.

Please see our privacy policy

Phone

This field is for validation purposes and should be left unchanged.