Referral Form

Referral Form
What is your relationship to the person who you would like to refer to our services?*

I am a family member or friendI am from a third party, another charity, trade association, external agency or an employer
Do you have consent from the person to make the referral? It is important that the person is aware of, and in agreement with, this referral.*

YesNo
We need the consent of the person who works in horticulture to proceed with the referral. Alternatively, you can encourage the person to contact us directly by speaking to our friendly helpline team on 0800 093 8543.
Details of referral
Please provide details of the person you are referring.
Name*

TitleFirst nameLast name
Date of birth

DayMonthYear
Phone number*
Email address
Address

Address line 1

Address line 2

City/TownCounty

Postcode
Can we contact them by phone?

YesNo
If we can contact them by phone, can we leave a message?

YesNo
Does the individual work in horticulture?*

YesNoRetired from a career in horticulturePreviously worked in horticulture (Please note, we are only able to support those people who have left a career in horticulture due to redundancy, a long-term health condition or because of caring responsibilities)
Please provide more information. For example, have they been made redundant or are currently unable to work in horticulture?
Area of support required. Please select ALL that apply.*

Debt adviceHelp with managing money / budgetingBenefits advice and informationHealth informationHousing informationEmployment and careers informationLegal advicePhysiotherapy serviceOther (please specify)
If other, please specify the referral reason
Please tell us more about why you are making this referral. Please provide as much information as you can to help our team support the individual in the best possible way.*
Please share information of any previous/current support provided by you as the Referrer.
Please share information of any previous/current support known to be provided by other agencies.
Has the person seeking support been referred to other similar services?

YesNo
Please provide more information about this.
Does the person you are referring have any additional needs that we need to be aware of? (e.g. accessibility needs, sensory or communication needs)
Is there any other information that you feel is relevant to the referral?
Your contact details
Name of your referring agency / third party organisation*
Name*

TitleFirst nameLast name
Email address
Phone number*
By ticking this box you are confirming you have permission to pass on the personal details of your service user / client and that you have obtained their explicit consent to share their Special Category Data with Perennial, as per the requirements of the General Data Protection Regulation (GDPR) 2018, where this applies.*

Yes
Date

DayMonthYear
Referral Form v1.0 last updated 28/03/2024
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Referral Form

Details of referral

Your contact details