Professional ReferralProfessional Referral Privacy Notice / ConsentCitizens Advice Doncaster Borough collects and holds your personal information. We use this information to:Make decisions about your support and advice needsHelp us to work with you and agree the support and advice you needWork effectively with others who may also provide you with support and adviceMake sure we manage our services effectivelyThis includes personal characteristics and sensitive information (special category data) relevant for the services we provide. The information we collect may be stored electronically, on paper or a mixture of both. We will not disclose any information provided ‘in confidence’ to anyone else without permission, except in the few situations where disclosure is required by law, or where we have good reason to believe that failing to share the information would put someone at risk.We need to obtain your consent to store your information and before doing so please read our privacy statement.Please ask your client to select one of the options below after reading this privacy statement to give their permission for us to hold their information * Yes NoReferrer's Personal Details Name * First Surname * Surname Job Title * Agency * Email Address * Telephone * Date Referred Client's Personal Details Name * First Surname * Surname Date of Birth * NI Number Email Address * Telephone * Address * Post Code * Communication Needs Sight Loss Hearing Loss Difficulty reading/writing Learning Difficulty Interpreter NeededHow would the client like to be contacted? Letter Text Phone EmailDoes this client require anybody to be with them at the interview? Yes No Details of person: Please tell us about anybody else that lives in the property Name: Relationship to client: Date of birth (if under 18): Name: Relationship to client: Date of birth (if under 18): Name: Relationship to client: Date of birth (if under 18):Service needsPlease tick all that apply to help us identify the best service(s) to meet your needs * Benefit/Income Issue Housing/homelessness Carer Debt/money worries Long Term Health Condition OtherOtherNeeds/Risk Assessment History of violence - Perpetrator History of violence - Victim Additional information Does the client have any other support workers? Name: Agency: Job Title: Telephone: Name: Agency: Job Title: Telephone: Name: Agency: Job Title: Telephone:MonitoringFor monitoring purposes please complete all sections. Tick only one box in each section.Gender * Male Female Do not wish to discloseEthnicity * White British White Irish White & Black Caribbean White & Black African White & Asian Indian Pakistani Bangladeshi Black Caribbean Black African Chinese Arabic Do not wish to disclose OtherOtherDo you consider yourself to have a disability? * No Yes Do not wish to disclose reCAPTCHA If you are human, leave this field blank. Submit
