WECIL Navigators Referral Form
The WECIL Navigator team are here to support Disabled people and their support networks with issues they may experience in daily life due to being Disabled.
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Have you used WECIL services before?
Yes
No
Not sure
How did you hear about us?
Word of mouth
Website/ google search
Using another WECIL service
Professional network
Are you....?
A Disabled person looking for help
A professional wanting to refer someone
A friend or family member of a disabled person
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Referrer's details
First Name
Last Name
Please enter the name of the organisation you work for if applicable
Please enter the relationship you have to the individual you are referring
Do we have consent to contact the person being referred directly?
Yes
No
Contact me first
What pronouns does this person use?
He/him
She/her
They/ them
Please enter your phone number
Please enter your email address
example@example.com
Name of person being referred
First Name
Last Name
Email of person being referred
example@example.com
Phone Number of person being referred
Address of person being referred
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the person needing help have any communication needs, or anything else that is relevant for us to know in order to support them? For example, is the communication preference email over phone, any particular time of day which is better to speak, interpreter required?
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Your name
First Name
Last Name
What pronouns do you use?
He/him
She/her
They/ them
Please enter your email address
Please enter your telephone number
How would you like to be contacted?
Phone
Email
Either
Other
Please enter your address
Street Address
Street Address Line 2
City
State / Province
Do you have any communication needs, or anything else that is relevant for us to know in order to support you? For example, is the communication preference email over phone, any particular time of day which is better to speak, you need a interpreter?
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Referrer's details
First Name
Last Name
Please enter the relationship you have to the individual you are referring
Are you referring a Disabled child/ children for support (25 and under)?
Yes
No
What pronouns does this person use?
He/him
She/her
They/ them
Name of person being referred
First Name
Last Name
Email address to contact
example@example.com
Phone Number of person being referred
Does the person needing help have any communication needs, or anything else that is relevant for us to know in order to support them? For example, is the communication preference email over phone, any particular time of day which is better to speak, any other communication preferences?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Name
First Name
Last Name
Phone number
Email
example@example.com
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Do you have an urgent deadline for your need for example, an application that needs to be returned?
Yes
No
I have a deadline but this is not urgent
N/A
Please could you tell us what the date is of your deadline if you have one
-
Month
-
Day
Year
Date
In as much detail as possible please tell us about your situation and what you would like help with
Important information regarding PIP (Personal Independence Payment) forms.
You are able to get at least 2 week extension to any deadline for PIP forms. We would recommend that you phone PIP to request this. The number to call should be on your PIP letter. If you don't have a form yet, please request a form so we can help you.
You can add any documents here which you feel would be useful (for example a letter you would like help with).
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To comply with the new data protection regulation (GDPR), please tick the box below. You have the option to have your data removed from our database of clients at any time. For removal of your data please email: hello@wecil.co.uk or phone 0117 947 9911.
I consent to WECIL holding the above data in line with GDPR
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