Referral Form

Who is making this referral?

Referral type*

Where did you hear about Oakleaf?

Have you had a show around in the last 3 months?

Yes

No

Referrers Full Name (if applicable)

What organisation do they work for?

Their contact number:

Their email address:

Their work address:

Personal Information

Full Name*

Email address

Contact Number*

Date Of Birth*

(DD/MM/YYYY)

Address

If supported name of consultant/CPN/support worker

Support workers contact telephone number

Can the support worker be contacted directly if necessary?

Yes

No

What would the referred individual like to change or achieve by attending Oakleaf?

1.

2.

3.

What is the referred individual's long term goal?

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.

GDPR- Full Name*

GDPR- Date*

(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

How would you describe your/the client's current mental health?*

Please let us know as much as possible about your/the client's past mental health:

Reason For Referal

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

Vocational Training

Upholstery

IT

Horticulture

Reason for choice:

Wellbeing Activities

(See calendar for details)

Wellbeing Activities

Which areas would you like to join activities?

Guildford Town Centre

North Guildford

Waverley

Bramley

Please list below any activities you would like to join which appear on our client activities calendar:

Counselling

Reason for choice:

Current social situation

Does the referred individual currently receive support from other services? Please specify.

Does the referred individual live independently?

Does the referred individual have any issues with drugs or alcohol? If so, please specify

Has the referred individual ever been convicted or found guilty by a Court of any offence (Excluding motoring offences and parking fines)*

Yes

No

Sign Name*

Date*

(DD/MM/YYYY)

Equality and Diversity Data

We would like you to complete this form in order to help us understand who we are reaching and to better serve everyone in our community. The information will be used to provide an overall profile analysis of our client base. If you would like the form in an alternative format or would like help in completing the form, please contact a member of staff. All information will be kept in line with GDPR regulations and you are under no obligation to complete this part of the Referral Form.