Refer

Please provide details of the individual you wish to refer

If you are considering referring a client, or unsure which service is best suited, we can help you decide what the best course of action.

PLEASE LIST WHAT SERVICE YOU’RE REQUESTING OTHERWISE WE MAY NOT BE ABLE TO PROCESS YOUR REFERRAL

PLEASE NOTE there is currently a waiting list on new referrals for our Kingston Service.

Full Name*

Email address*

Contact number*

Address*

Date of birth*

What service do you require*

What is the main assistance you require?*

What other assistance you require?
(Please include as much detail as you are able to provide)

Do you require any adjustments to access our service
(eg. wheelchair access, travel difficulties, language barriers)?*

If you have spoken to a mental health professional about this referral.
Please give their name and the team they work in*

Signed by (your name)*

Date*

Data Protection: The information obtained here will be used in compliance with the Data Protection Act 2018 and General Data Protection Regulation (GDPR) (EU) 2016/679. Electronic and paper records will be kept secure, with access limited to only those people who need to see the information for the purposes of processing this referral. Some information may be shared with other support agencies where necessary to access further services or to ensure integrated service delivery. If you would like to know more about the storage and use of personal information or would like to access your file, please contact Working Well Trust.

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Please provide details of the individual you wish to refer