Have Your Say - Kent Consent In just three minutes, you can make a difference. Share your views on health or social care services in Kent. Tell us what works and what needs improvement. Your experience will help us tell NHS and social care services how to make your care better. The information you share with us is anonymised and will not affect your care. We form part of a family of projects which work together to drive positive change for everyone. To do that we need your permission to share your information within Engaging Kent CIC, trading as EK360.Are you happy for us to:Record your story and share anonymously with health and social care organisations that provide services and decision makers so they can hear your voice.Share your information within EK360. I Agree main Tell us about your experience When did this happen? Please give an approximate date or timespan. Please tell us about your experience. What went well or did not go well? Were there any services involved? Please give details. Such as care home name, GP surgery name, hospital name and department, social care service name. How could your experience have been improved? Is this experience about you or someone else? About me About someone else Experience as a professional Demographics Tell us a bit about you It would really help to know a little more about you so that we can better understand how people's experiences may differ. These questions are completely voluntary, if you do not want to answer any of the questions please tick ‘prefer not to say’ Please fill out the following based on your own demographics. Which district do you live in? Ashford Canterbury Dartford Dover Folkestone and Hythe Gravesham Maidstone Medway Sevenoaks Swale Swanley Thanet Tonbridge and Malling Tunbridge Wells None of the above Prefer not to say Please specify if you wish: What Medway area do you live in - Select -AllhallowsChathamChattendenCliffeCliffe woodsCoolingCuxtonGillinghamHallingHempsteadHigh HalstowHolboroughHooIsle of GrainLordswoodParkwoodRainhamRochesterSheppySittingbourneStokeStroodTwydallUpnorWainscottWaldersladeWigmoreWouldhamNone of the abovePrefer not to say What is your postcode? How would you describe your gender? Female Male Non-binary Prefer to self-describe Prefer not to say Please describe if you wish: Is your gender identity the same as your sex recorded at birth? Yes No Prefer not to say What age group are you in? 0-9 10-17 18-24 25-34 35-44 45-54 55-64 65-74 75-84 85-94 95+ Prefer not to say Are you 25? Yes No Prefer not to say What is your ethnicity group? - Select -Asian BritishBangladeshiIndianNepalesePakistaniAny other Asian/Asian British backgroundBlack BritishAfricanCaribbeanAny other Black/Black British backgroundWhite & AsianWhite & Black AfricanWhite & Black CaribbeanAny other mixed/multiple ethnic backgroundWhite BritishGypsy or Irish TravellerIrishRomaAny other White/White British backgroundArabAny other ethnic groupPrefer not to say Please describe if you wish: Please describe if you wish: What is your sexual orientation? Hetrosexual or straight Gay or lesbian Bisexual Pansexual Asexual Queer Prefer to self-describe Prefer not to say Please describe if you wish: Do any of these apply to you? Disability Mental health issue Long-term health condition Neurodiversity Prefer not to say Please describe your disability if you wish: Please describe your mental health issue if you wish: Please describe your long-term health condition if you wish: Please describe your neurodiversity if you wish: Do you consider any of these to be a disability? Mental health issue Long-term health condition Neurodiversity Prefer not to say Are you a carer for another person? Yes No Not sure Prefer not to say Is English your first language? Yes British Sign Language (BSL) No Prefer not to say Please tell us your first language if you wish: What is your present religion, if any? Prefer not to say What is your employment status? Prefer not to say What is your highest level of education? Prefer not to say In the past six months have you struggled to pay for basic necessities? Never Rarely Sometimes Often Always Don't know Prefer not to say Are you currently homeless or at risk of becoming homeless in the near future? Currently homeless As risk of becoming homeless in the near future No Other Not sure Prefer not to say Please give details if you wish: Are you a refugee, asylum seeker or migrant? Yes No Not sure Prefer not to say We use this information to help us spot trends to identify areas for improvement. We may use quotes in our reports, but we will not use any personal information that will identify you without contacting you first. Find out more about how we handle your information, including how to withdraw consent in our privacy statement. Please fill out the following based on your own demographics. Would you be happy for EK360 to contact you: To ask you more about this experience if needed? Yes No To take part in future work we are doing and share other health and social care experiences? Yes No Receive our newsletters? Yes No CONTACT AND CONSENT First name Last name Phone number Email address Where did you hear about Healthwatch Kent? Test