How does it feel for me? interest form

We anticipate that several people maybe interested in this opportunity and we only have one or two spaces. In order to check your suitability for the How does it feel for me? project and to help us make our decision, we'd like to ask a few questions about you or the person you care for. Please note that any information that you provide on this form will be stored securely, and not shared with anyone outside of Healthwatch Leeds.

If you prefer to answer these questions over the phone, please call 0113 8980035

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* 1. What is your full name?

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* 2. What is your email address?

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* 3. What is your phone number?

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* 4. How do you prefer to be contacted? (tick as many as you like)

Phone

Textphone

No preference

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* 5. Do you or the person you care for have on average more than one appointment/contact with a variety of different health or social care professionals in Leeds each month?

Yes. as a patient

Yes, as a carer

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* 6. To help give us an idea of the kinds of interactions you have with health and care services, please list brief details of the health and care services you or the person you care for have had contact with in the last 3 months.

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* 7. Please use the space below to give brief details about your health conditions/social care needs that you currently get treatment or support with.

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* 8. Are you willing to participate in recorded interviews (audio/video and anonymously if you wish) approximately once a month for at least 6 months?

Yes

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* 9. How would you/the person you care for describe their ethnicity?

Indian

Pakistani

Bangladeshi

Chinese

Caribbean

African

English, Welsh, Scottish, Northern Irish, or British

Jewish

Gypsy or Irish Traveller

Arab

Prefer not to say

Any other ethnic group (please specify)

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* 10. Do you/the person you care for have a learning disability?

Yes

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* 11. Which area of Leeds do you live in?

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* 12. Please tell us about any support to communicate?, e.g. Interpreter, documents in large print etc

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* 13. Healthwatch Leeds offers a range of other opportunities for you to contribute to service improvement by sharing your experience. Would you like to be added to our mailing list to hear about future opportunities? (don't worry we won't bombard you with things!).

Yes

Thank you for sharing your details. We will let you know if you have been selected to take part in the How does it feel for me? project.