ClearCommunityWeb Partner Referral
Please complete the following for if you would like to refer a person for individual support. The first page is your details so we can keep you informed about progress and the following pages are about your referral and the support they need. If you feel they would benefit from one of our classes you can refer to our calendar www.clearcommunityweb.co.uk/calendar for more information. Please feel free to share.
Your Details
Your Name
*
First Name
Last Name
Your Contact Number
*
Please enter a valid phone number.
Your Alternate Number
Please enter a valid phone number.
Your Email
*
example@example.com
Your Borough
*
Please Select
Bromley
Croydon
Lambeth
Southwark
Wandsworth
Sutton
Lewisham
Hackney
Westminster
Hammersmith
Camden
Islington
Other
Your Organisation
How did you hear about us?
Back
Next
Resident Details
Resident Name
*
First Name
Last Name
Resident Contact Number
*
Please enter a valid phone number.
Resident Alternate Contact Number
Please enter a valid phone number.
Resident Email Address
example@example.com
Resident Borough
*
Please Select
Bromley
Croydon
Lambeth
Southwark
Wandsworth
Sutton
Lewisham
Hackney
Westminster
Hammersmith
Camden
Islington
Other
Resident Address
Street Address
Street Address Line 2
City
County
Postcode
Would you like us to contact this resident directly?
Yes
No
Back
Next
How can we help?
Subject
*
Further explanation - please explain in as much detail as you can why you feel this person could use our help.
*
Which device is this person having problems with?
Does this person have Wi-fi?
*
Yes
No
Does this person have difficulty with:
Seeing
Hearing
Neither
Does this person have mobility issues?
Yes
No
Don't know
Is this person a carer for the owner of the device, or assisting someone else?
Yes
No
Don't know
Additional support needs or considerations
I have been given consent to share these details with ClearCommunityWeb
*
Yes
Submit
Should be Empty: