Safe Online Referral

Safe Online Referral Form

"*" indicates required fields

Your Details

These details refer to the person who is submitting the referral. In case of queries relating to this referral, we will use these details to contact you. (If you are submitting a referral on behalf of yourself, please enter your details in this section and again in the Client Details).

Your Name*

First Last

Your Email Address*

Enter Email Confirm Email

Your Telephone Number*

Your Organisation

Client Details

These details refer to the person that you'd like the Safe Online Scheme to support.

Client's Title

Client's Name

First Last

Client's Telephone Number

Client's Address*

Client's Date of Birth*

Type of Referral

Please select an option to indicate how the client meets our referral criteria.

Type of Referral

Please note providing as much information as possible in your initial referral enables the Trust to visit the client quickly by avoiding delays in gathering missing information.

Please give a brief description for the reason a visit is required including any areas of particular concerns. Also please advise if there is a need for a carer/supporter/family member to be present at the time of the visit including a contact name and number.

Reason for referral*

Does the client suffer with any form of dementia or mental health?

Yes

If yes, please give details, including carers name and contact telephone number

Please note that we may be unable to visit a client suffering with dementia or mental health issues without a carer/second person present

Are there any risks posed to our Adviser attending alone, and if so, what?

Ensuring our Adviser's safety when attending alone is of paramount importance to us. Failure to provide accurate answers to any of these questions will result in us declining to attend.

Confirmation

By submitting this form, you confirm that the client has given their permission for you to pass their information to the Trust and that the client is aware that we will make contact with them.

We take data protection very seriously, and do not share or use your data in any way, other than to respond to you to help with your enquiry.

To see our policies regarding use of your data, click here

If you are happy to proceed on this basis, please tick the box below. Otherwise call us on 0300 777 0157 so we can manage your enquiry by phone.

Your Data*

By using this form you agree with the storage and handling of your data by this website.

Safe Online Referral