Referral

In light of the current crisis we are opening this referring system to all legitimate local and national agencies – please ensure you have your client’s permission to share their information with us for assistance.

Your organisation:

Your name *

First

Last

Your email: *

Your telephone number: *

Client name: *

First

Last

Client email:

Client telephone number:

Please provide either a telephone number or email so we can contact the client.

Client address:

Is the client in dispute with another individual? *

Has the client presented any behaviour that is contrary to the well-being of staff? *

Primary issue you would like us to help with: *

Please add any additional information to help us allocate the right help for the client (e.g. literacy or language barriers, digital help, physical or mental health problems):

Please confirm the client has consented to this referral: *

The client is aware of and has agreed to this referral.

I would like to know the outcome of this referral.

We will ask the client for consent to provide feedback to you.

Do you consent for us to store the information you have provided in accordance with our privacy policy: *

I agree.

If the client is in dispute, or has presented a concern to the well-being of staff we will need to contact you for further information before we proceed with the referral.