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North Tees and Hartlepool NHS Foundation Trust
Referral Form – Citizens Advice Hartlepool
Consents
For further information about how we store and use the data gathered, please see our
privacy policy.
Before using the referral form, please confirm the following:
Q1.
The Client/Service User agrees to this referral and for Citizens Advice Hartlepool to hold any personal data provided.
Please select
The client/service user gives consent for the referral and the storing of their information.
Q2.
The Client/Service User understands that Citizens Advice Hartlepool will gather and store the data for the provision of advice, to improve the service, and to support research in a way that the client can not be identified.
Please select
The client/service user confirms they understand the purpose Citizens Advice Hartlepool will use their information for.
Q3.
The Client/Service User has provided explicit consent for special category personal data related to health to be passed to and held by Citizens Advice Hartlepool.
Please select
The client/service user gives consent for information relating to health to be stored and processed by Citizens Advice Hartlepool.
Q4.
The Client/Service User understands that they can withdraw consent at any time by Contacting Citizens Advice Hartlepool.
Please select
The client/service user confirms they understand their consent can be withdrawn at any time.
Q5.
I understand this form must be completed with the Client/Service User, and the following answers in relation to consent have been discussed with the Client/Service User.
Please select
Yes
North Tees Referral Form
Name of Referrer
Organisation
Department/Team
Contact Details
Telephone
Secure Email
Client/Service User Case Details
Name of Client/Service User
Date of Birth
Date of Referral
Address
Postcode
Landline Number
Do we have permission to leave message on landline?
Please select if you have permission
Yes
No
Mobile Number
Do we have permission to leave message on mobile?
Please select if you have permission
Yes
No
Email
Do we have permission to leave message on email?
Please select if you have permission
Yes
No
Are Their Any Issues Regarding Contact?
Health Conditions
Reason For Referral
Select reason for referral
Please select reason
Benefit Claim Form
Energy Advice
Housing
Debts
Financial Problems
Benefit
Community Care (Please Provide Details Below)
Are there any emergencies or deadlines we need to be aware of?
Any Other Information (If Relevant)
Submit
