Macmillan Referral form

1 | Permissions Collected by Referrer

Date of Referral (required)

Permission to refer your client to Citizens Advice Warrington (required)
Yes

Permission for Citizens Advice Warrington to share information on advice given to client with your referral agency?
Yes

By ticking these boxes, you are confirming you have permission to pass on the personal details of your client and all relevant data to their enquiry.

Please ensure your client is aware of our privacy policy.

2 | Referring Agency Details

Name of Organisation:

Please selectAintree HospitalBridgewater NHSClatterbridge CCDelamere CentreHalton HospitalHaydock & Newton PCNLiverpool Mac SupportLiverpool Women's HospitalMersey & West Lancashire HospitalRoyal Liverpool HospitalSt Rocco's HospiceStroke AssociationWarrington Borough CouncilWarrington Disability PartnershipWarrington HospitalWarrington Housing AssociationWarrington Voluntary ActionWBC Dementia Wellbeing teamWhiston HospitalWBC Wellbeing TeamOther

Name of Department:

Name of Referrer:

Referrer Role:

Referrer Contact Number:

Referrer Email Address:

3 | Who to Contact

When you make a referral, we can contact the client directly or they can provide permission to speak to someone else who will act on their behalf.

Contact Client Directly – move to section 4Contact a person acting for Client – complete section 3

Name of person acting for Client

Relationship to Client

Contact telephone number

Contact Email address

Do they have Power of Attorney for client? YesNoNA

Are they a DWP Appointee for client? YesNoNA

4 | Client Details

Full Name (required)

Date of Birth (required)

Address (required)

Postcode (required)

Email address (required)

Phone Number (required)

Contact in any of the ways providedDo not leave a voice mailDo not send text (SMS)Do not send a letterDo not send an email

National Insurance Number

GP Surgery

Do any of the following apply to your client?
Torus TenantWHA TenantArmed Forces Veteran

Ethnicity
Please selectWhite – English, Welsh, Scottish, N. IrishWhite – IrishWhite – Gypsy or Irish TravellerWhite – OtherMixed – White & Black CaribbeanMixed – White & Black AfricanMixed – White & AsianMixed – OtherAsian or Asian British – BangladeshiAsian or Asian British – ChineseAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – OtherBlack or Black British – AfricanBlack or Black British – CaribbeanBlack or Black British – OtherArabRomaPrefers not to sayUnknown

Gender
Please selectManWomanNon-binary, gender-fluid or gender queerUnknownPrefers another termPrefers not to say

Nationality

First Language

Interpreter Required

5 | Health

Is an SR1 applicable?
YesNo

If yes, please attach to referral form.

Please provide a brief description of diagnosis

6 | Issue

DebtBenefitsHousingEmploymentImmigrationConsumerRelationship/ Family IssuesOther

Reason for referral

Any urgent deadlines related to the issue

7 | Support Needs

Support Needs
Are there any support needs we need to consider when contacting your client?

Risk factors
Are there any risk factors we need to consider when contacting your client?

8 | Supporting Evidence

To allow us to quickly advise your client, we will require supporting documents you hold.
Failure to supply these documents at initial referral will lead to a delay in support for your client.

NoneSR1Other (please describe below)

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