RVT – Agency Referral

Agency Referral to The Road Victims Trust
Please ensure that the person you are referring is aware you are giving us their contact details.

Please do not promise a call on a specific day or time but state that we will do our best to call them within 2 working days.

If the person needs urgent help, please contact the appropriate emergency service for this and, if you continue to make this referral, advise us if you have done this.

*Indicates required fields.
Details of Referring Agency
Agency name*
Referrer's name*
Your job role*
Your contact number*
Your email*
Has the client given permission for The Road Victims Trust to contact them?*

YesNo
Please obtain client’s consent to us contacting them prior to completing this form.
Client being referred
First name*
Last name*
Date of Birth*

DayMonthYear
First line of address
Town
County*
What County?*
Postcode*
Email*
Telephone number 1*
Telephone number 2 (optional)
Further information about client from referrer
Brief reason for contacting us*

0/250
Any physical or mental health issues we may need to know about

0/250
Further Information about the collision from referrer
Collision date*

DayMonthYear
Collision County*
What County was the collision?*
The Road Victims Trust services are available for those who reside in Bedfordshire, Cambridgeshire, or Hertfordshire, or where the collision happened within one of these counties. You may still submit this form, and someone will be in touch with you about referring you to a national service or one local to you.
Collision circumstances

0/250
Referring person's relationship to deceased / injured person / collision*
Name of deceased / injured person (if known)
Police contact (if available)
Please verify that you are human*
Should be Empty:

Agency Referral to The Road Victims Trust

Details of Referring Agency

Client being referred

Further information about client from referrer

Further Information about the collision from referrer