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. Please complete this form as fully as possible to help our team process your referral.
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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?
*
Please Select
A Disabled person looking for help
A Professional wanting to refer someone
A friend or family member of a Disabled person
A member of the WECIL team
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Person making the referral.
Name
*
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
*
Are you referring a Disabled child/ children for support (aged 25 and under)?
Yes
No
Do we have consent to contact the person being referred directly?
*
Yes
No
Contact me first
Please enter your phone number
*
Please enter your email address
example@example.com
About the person needing support
Name of person being referred
First Name
Last Name
What pronouns do they use?
He/him
She/her
They/ them
Ethnicity
White
Asian or Asian British
Black or Black British
Mixed multiple heritage
Prefer not to say
Date of birth
*
-
Day
-
Month
Year
Date
Email of person being referred
example@example.com
Phone Number of person being referred
How would you they like to be contacted? (select all relevant)
Phone
Email
Either
Other
Address of person being referred (we must have a post code as a minimum)
*
Street Address
Street Address Line 2
City/ Local Authority
State / Province
Postal / Zip Code
The person's impairment (disability) and health condition information. We are asking for this information so we can provide the person with the best possible support and understand your needs as much as possible.
A physical impairment
A sensory impairment (e.g. limited/ no hearing or sight)
Neurodivergent
A long term health condition e.g. cancer
A medical condition which you should be aware of e.g. epilepsy
Mental health needs
A learning difficulty or disability
Prefer not to say
Other
If selected 'other' please provide further information.
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? Can you provide any further information about their impairment or health condition which would help us to provide the best possible support.
*
Is there anything else we need to be aware of for example current safeguarding concerns, health or mental health conditions which we should be aware of, safety risks which could impact our staff? Please note, due to high demand we can only accept referral forms which are complete and give us as much information as possible.
*
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About you- Disabled person looking for support.
Your name
*
First Name
Last Name
What pronouns do you use?
He/him
She/her
They/ them
Date of birth
*
-
Day
-
Month
Year
Date
Ethnicity
White
Asian or Asian British
Black or Black British
Mixed multiple heritage
Prefer not to say
Contact information
Please enter your email address
Please enter your telephone number
*
How would you like to be contacted? (select all relevant)
Phone
Email
Either
Other
Please enter your address (we must have a post code as a minimum)
*
Street Address
Street Address Line 2
City/ Local Authority
State / Province
Your impairment (disability) and health condition information. We are asking for this information so we can provide you with the best possible support and understand your needs as much as possible.
I have a physical impairment
I have a sensory impairment (e.g. limited/ no hearing or sight)
I am neurodivergent
I have a long term health condition e.g. cancer
I have a medical condition which you should be aware of e.g. epilepsy
I have mental health needs
I have a learning difficulty or disability
Prefer not to say
Other
If selected 'other' please provide further information.
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, you need to meet in person?
Is there anything else we need to be aware of for example current safeguarding concerns, health or mental health conditions which we should be aware of, safety risks which could impact our staff?
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What can WECIL Navigators support you with?
I would like help with...
Filling in a form
Finding the right care and support for me
Help with employment
Help with challenging a decision which I don't think is right
Help to connect to my community
Help for my child/ children
Help to apply for a grant
I'm not quite sure what help I need
Other
I think my enquiry is...
Very urgent (for example, you are at risk of losing your home, you are struggling to cope at home, you have a deadline)
Important but not urgent (for example, I need help filling in a form but there is no deadline, I have care in place but I think this should change)
Not urgent but I would like help soon (for example, I would like to explore my options for finding support in my community, I am thinking about returning to work)
Do you have an urgent deadline for example, an application or form 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
-
Day
-
Month
Year
Date
In as much detail as possible please tell us about your situation and what you would like help with. The more information we have, the easier it is for one our team to help you.
*
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. https://wecil.org.uk/wp-content/uploads/2022/10/WECIL-Privacy-Policy.pdf
I consent to WECIL holding the above data in line with GDPR
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