Adult Referral Form

Service user details

Client name

Date of birth

Landline phone number

Mobile phone number

Address

Street Address Address Line 2 City County Post code

Email

How would you like to be contacted?

Landline phone

Mobile phone

Post

Email

Is it safe to: (tick as necessary)

Leave a message on the telephone numbers you have given?

Identify ourselves to your carers/partner etc on the phone?

Leave you messages via email?

Mark envelopes ‘Private and Confidential’ if we write to you?

First language/languages spoken

Language requirements

Interpreter required

Sign language interpreter required

GP and medical history

GP Name and Surgery

Address

Street Address Address Line 2 City County Post code

GP Phone number

Medical history (optional)

Medication

Allergies

Dietary needs

Disabilities (neurodiverse/ Physical etc)

Referrers information

If you are referring yourself please skip this section

Referrer’s name

Referrer’s organisation

Referrer’s email

Referrer’s phone number

Reason for referral

Emergency Contact

Who should we contact if an emergency happens while you are with us?

Please remember that you may prefer this person to know you are having counselling with us, in case we have to call them in an emergency

Emergency contact name

Emergency contact address

Street Address Address Line 2 City County Post Code

Emergency contact phone number

Emergency contacts relationship to you

Privacy Statement

We are collecting your personal details and GP details to use during our work together. In case of crime or harm to yourself or others, I would need to contact the appropriate authorities. My need for knowing your medication or medical conditions, is to be aware of how these affect you during our work together.

CONFIDENTIAL - EQUALITY & MONITORING

At Alumah we are committed to promoting the best equality practices in our efforts to eliminate discrimination and create environments where all are treated fairly and with respect. We are committed to ensuring that anyone who works at, or uses Alumah, is not treated less favourably than anyone else because of their race, ethnic or national origin, culture, religion, disability, age, gender or sexual orientation.

We will use the information you give us to help monitor the effectiveness of our Equal Opportunities Policy and to help drive our policy and development.

This form is completely confidential. We will never use this information to identify individuals, so please do not add your name.

Consent

To allow Alumah using photos or short videos, which may include the individual in local publications, our social media and website. Please tick the box. N.B most photos will be of projects produced.

Emergency first aid considered necessary N.B. the medical profession takes the view that parental consent to medical treatment cannot be delegated. Medical forms have no legal status, and a doctor has the right to insist on parental consent before treating a child. We have found, however, that medical staff find this type of general consent helpful.

Are you happy for us to keep and store your information on our database? (This is NOT shared with anyone else, unless discussed with you). We need a record of your information to make sure we are working safely and ethically as well as being able to see that you are getting the support you need. We also need to be able to add you to our waiting lists if necessary and without consent to use our database we will be unable to do this.

Are you happy for us to use any feedback you give us?

Adult Referral Form

Service user details

GP and medical history

Medical history (optional)

Referrers information

Services

Section Break

Counselling

Support

Social worker

IDVA

Probation

CPN

Money Advisor

Housing support worker

College

University

Other key worker (please describe)

Emergency Contact

Privacy Statement

CONFIDENTIAL - EQUALITY & MONITORING

Confidentiality & Exceptions

Ethnicity