Referral Form

Referral Form

Page 1 of 6

Who is making this referral?

Personal Information

(DD/MM/YYYY)

1.

2.

3.

GDPR Statement

Oakleaf Enterprise are the Data Controller of the information you have provided. Due to the nature of our work with you, we are required to collect personal data about you which will include special categories of personal information. This information will only be collected from you and used by us to assist you, it will not be shared with third parties unless the law allows. We have a data protection regime in place to oversee the effective and secure processing of your data, we will hold your information for 6 years unless you instruct us to delete it once the relationship has ended. We would like to be able to send you information and /or reminders about activities and appointments by post, telephone email and/or SMS. If you agree to being contacted in this way please sign below.

(DD/MM/YYYY)

Mental Health Information

Please give us as much information as you can regarding the mental health conditions of the person being referred and how they affect them

Reason For Referal

What would the referred individual like to do at Oakleaf and why? Please specify which activity/activities they are interested in:

(See calendar for details)

Which areas would you like to join activities?

Current social situation

(DD/MM/YYYY)