Branching Out: Professional Referral Form

Branching Out: Professional Referral

For completion by a professional (e.g. social worker, GP, probation, hostel staff, support worker) referring a client/patient for support.

Page 1 of 5

Contact Information

Please provide information on how we can contact you.

Type either an email address or a telephone number, depending on which is the better way to contact you.

What company/organisation are you referring from?

The full name of the client you are referring

Please select at least one.

Please provide your telephone number

Disadvantages

The client must be experiencing two or more of the following to qualify for the service.

Please tick all that apply.

Risk

Based on your assessment of the client/patient/service user:

If you feel that you are currently a risk to yourself or others, or that you are at risk from someone else, please provide details.

Please provide an up-to-date risk assessment if you are able to by emailing it separately to russelllewis@oakleaf-enterprise.org.

Please provide details

Medical Conditions

E.g. severe allergies, epilepsy, heart conditions, diabetes.

How We Use and Store Data

Oakleaf is the data controller of the information you have provided. Due to the nature of our work with you, we will, from time to time, collect personal data which will include special categories of personal information. Beyond your name, date of birth and contact details, this data may also include information about your health and other personal characteristics you may have shared with us. This will allow us to take any reasonable steps to accommodate specific needs or requirements you have when providing our services to you and we require your specific consent to process this information. Full details can be found in our Fair Processing Notice.  

Your referral is almost complete...

To submit your form, please press the 'send' button below. Your referral will be sent to our Outreach Worker who will contact you within 7 working days.