Client Referral Form

Client Referral Form
Please note: We aim to contact all referrals within 3 working days. If the contact method is Telephone we may call from a withheld number.
Name of Referring Professional*
Job Title*
Practice or Organisation*
Department
Email*
example@example.com
Phone No*
Signed*

Clear
Reason for Referral
Reason for Referral (Please tick boxes as appropriate)*

Help with BenefitsEmployment issuesMoney, debt and credit problemsHousing and HomelessnessImmigration and residency queriesConsumer issueHuman rights / discriminationFamily, relationships, personal issuesOther
Please give brief details of issue and any other comments you wish to make:
Client Consent
Citizens Advice St Albans District needs the client’s explicit consent to use special category personal data to give the client advice, help us gather data to improve our service, and support our research in a way that the client can’t be identified. We’ll make sure the client’s information is kept safe in our secure case management system. We only access the client’s data when we have a good reason, we only share what is necessary and relevant, and we don’t sell the client’s data to commercial organisations.
The Client has consented to this referral*

YesNo
The client consents to Citizens Advice St Albans District recording their personal data and special category personal data including ethnicity, religion, health conditions, sexual orientation and trade union membership.*

YesNo
Citizens Advice wants to make sure our service meets your needs. To help us understand how we’re doing and to improve our service, we may want to contact the client at a later date to ask for their feedback. Sometimes we need a trusted research organisation to help us do that. We’ll decide who we contact for feedback based on the services the client used and the advice area. We may also use the client’s special category data so that we hear from different groups.

Please tick the box below if the client agrees to us getting in touch.
The client agrees to Citizens Advice selecting them for feedback, using their information and contacting them.*

YesNo
Client Details
Client Name*

First NameLast Name
Client Address*

Street Address

Street Address Line 2

TownCounty

Post Code
Email
example@example.com
Phone No
Ok to leave a message*

YesNo
Preferred contact method*
Should be Empty:

Client Referral Form

Client Consent

Client Details