Referral Form

Before you start...

Before making a referral have you or your client researched the issue via the Citizens Advice website, by using our Virtual Adviser tool or by using a benefit calculator to check entitlement? If you have, or if you feel further advice and assistance is needed, please continue. Otherwise please exit this form and explore the considerable amount of advice and assistance available online.

Essential information

In order to process this referral, we need to record details of your client/patient.

To submit this form, you must have gained their permission or consent to share with us the information you have provided below.

For more information about what we do with personal data please read our Privacy Notice.

Referrer’s details

Referrer's Name*

Prefix First Last

Referrer’s Job Title / Role*

Referrer’s Organisation*

Referrer’s Email*

Referrer’s Phone Number*

Please let us know if you have completed our Advice First Aid training*

Yes

Reference Number

If your organisation has a reference number that applies to this referral please list it below

Client’s details

About the person you are supporting

Client's Name*

Prefix First Last

Client's Date of Birth*

Client's Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Client's Email

Can we send an email?*

Yes

Client's Mobile Phone

Note - when contacting your client OUR number may show as withheld or unknown. Please make sure your client is aware of this.

Can we leave a voicemail?*

Yes

Can we send a text message?*

Yes

Client's Landline Phone

Note - when contacting your client OUR number may show as withheld or unknown. Please make sure your client is aware of this.

Can we leave a voicemail?*

Yes

First Language

Are there any barriers to advice, or vulnerabilities, that we should be aware of?

e.g. literacy or numeracy difficulties, a need for a BSL or other language interpreter.

Is there anything else we should know, including anything for risk assessment or safeguarding purposes?

Nationality*

Household Type*

Housing Type*

Please provide ages and genders of children, if known

For Example:
boy 9
girl 12

Marital Status*

Employment*

Where to direct your referral

Referral Option*

Please select the most appropriate referral option from the drop down list, this will ensure we get your referral to the right advice team quickly.

Debt – advice for people with budgeting or debt related issues
Housing – advice for people with housing or homelessness related issues
Litigants in Person – family law advice for survivors of domestic abuse
Macmillan – welfare benefits help for people affected by cancer
MS – advice on any topic for people affected by Multiple Sclerosis
Cygnet Healthcare & Elysium Healthcare – for referrals from staff and advocates working in these hospitals
Health Connections Mendip - for referrals from Mendip GP practice social prescribing and health coaching team
Advice HPC – for people living or working in the Hinkley Point C area (from Brean to Minehead)
Anything else

About your client’s situation

Can you tell us a little about their situation and/or their advice needs

Please select all that apply

Debt, money and housing

What is the source of income for the household?*

What benefits is your client's/patient’s household currently in receipt of?

Please tick all that apply

Income and savings

Please can you tell us about their income and capital?

e.g.

How much they receive from individual benefits
Other income sources and amounts (pensions, wages etc)
Savings or investments

Debt and money

Please can you tell us about any financial difficulties?

e.g.

Who do they owe money to
How much

Housing or homelessness

Please can you tell us about any housing or homelessness advice needs or their housing situation

e.g.

who their landlord or mortgage provider is,
have they made a homelessness application,
have they registered for Homefinder Somerset etc.

Litigants in Person

Please only refer your client to the Litigants in Person team if you client can meet all the following:

have experienced domestic abuse
need advice about their rights or help with court action against their perpetrator/abuser
are not eligible for Legal Aid

Has your client experienced domestic abuse?*

Yes

Does your client have a legal issue against their abuser/perpetrator?*

For example, to do with their home, children, finances, divorce/separation.

Yes

Reason for referral*

Please provide as much detail as possible e.g. relevant background, advice need, what your client has done so far etc.

If known, please confirm the name of your client’s perpetrator/abuser

Essential Questions

Urgent or emergency advice need

Are there any key dates or urgent deadlines we need to be aware of e.g. eviction, court or bailiff action?*

Yes

Please tell us the key dates or deadlines and what they are*

Client Support

How are you assisting the client?*

Will you be continuing to support your client after you've referred them?*

Yes

Is your client receiving any other specialist support of involvement?*

Yes

Please tell us who and how they are assisting*

Multiple Sclerosis Referral Questions

Diagnosis details*

Not known

Relapsing and remitting MS

Secondary progressive MS

Primary progressive MS

Date of Diagnosis*

Reason for advice referral and any other information

(e.g. please describe their current situation, what they need advice about, what they hope to achive etc)

Macmillan Referral Questions

For referrals from hospital staff - please let us know which department you work in.

Are you a Macmillan (badged) Health or Social Care Professional.*

Yes

Diagnosis details (and treatment plan if known)*

Date of Diagnosis*

Terminal Prognosis? Is a SR1 needed?*

SR1 = special rules, death can reasonably be expected within 12 months

Yes

Not sure, I’d like to discuss this with you

If your patient is special rules, can you upload the SR1?*

If you are unable to upload the medical evidence, please ensure you detail all the information in the box below.

Yes

Reason for advice referral

(please describe their current situation, what they need advice about, what they hope to achieve etc)

Clinical Nurse Specialist Name*

Cancer Nurse Specialist Phone Number*

Location of Treatment*

Is your patient being supported by a family member or close friend?*

please note: we will attempt to speak to your patient first.

Yes

Details of family member or close friend

Supporters Name*

Prefix First Last

Relationship*

Supporters Email Address

Supporters Phone Number*

Advice HPC

Please select which HPC area your client lives in*

Anything Else

Further details about your referral*

Please provide as much information about the issue the client/patient is facing or the advice they need, and any information we should be aware of prior to contacting the client.

Supporting information / documents

Can you provide any documents that may help us to assess your client/patient’s situation and provide advice?

For example, benefit letters, UC payment statements, bank statements and council tax bills. If so, and they are available electronically or you can take pictures of them, please upload them here

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, xls, xlsx, Max. file size: 5 MB, Max. files: 5.

Before you start...

Essential information

Referrer’s details

Client’s details

Where to direct your referral

About your client’s situation

Debt, money and housing

Income and savings

Debt and money

Housing or homelessness

Litigants in Person

Essential Questions

Urgent or emergency advice need

Client Support

Multiple Sclerosis Referral Questions

Macmillan Referral Questions

Details of family member or close friend

Advice HPC

Anything Else

Supporting information / documents

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Before you start...

Essential information

Referrer’s details

Client’s details

Where to direct your referral

About your client’s situation

Debt, money and housing

Income and savings

Debt and money

Housing or homelessness

Litigants in Person

Essential Questions

Urgent or emergency advice need

Client Support

Multiple Sclerosis Referral Questions

Macmillan Referral Questions

Details of family member or close friend

Advice HPC

Anything Else

Supporting information / documents

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Connect With Us

Information

Service Feedback

Secure Portal

Connect with us