Information and Signposting Healthwatch Kent Consent 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 form introduction Information and Signposting Navigating the health and social care system can be hard. Maybe you need to find a particular service near to you, or perhaps you’ve had a bad experience and you want to know how to make a complaint? Do you need to know what your rights are? Whatever it is, we will try and help you, let us know what you need help with on the form below and we’ll get back to you with the information that you need. ___________________________________________________ questions 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? Please tell us what help you need? Optional question 2 Is this experience about you or someone else? About me About someone else Experience as a professional Demographics Information and Signposting Questions Are you enquiring for yourself or on behalf of someone else? Myself Someone Else What service does your enquiry relate to? For example, is it about NHS dentistry, or a particular GP practice or Care Home? Please tell us what help you need? Please fill out the following based on your own demographics, not those of the other person. 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 - None -MedwayAllhallowsChathamChattendenCliffeCliffe woodsCoolingCuxtonGillinghamHallingHempsteadHigh HalstowHolboroughHooIsle of GrainLordswoodParkwoodRainhamRochesterSheppySittingbourneStokeStroodTwydallUpnorWainscottWaldersladeWigmoreWouldhamNone of the abovePrefer not to sayDid not 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 contact consent 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 closing items Where did you hear about Healthwatch Kent? For more information or to withdraw consent, please see our privacy policy. Thank you for taking the time to get in touch. We will reply to you as soon as possible, this can take up to ten working days. Test