Referral Form

Referral Form

Click here to download our Service Directory.

CLIENT CONTACT DETAILS

Name (required)

Address (required)

Postcode (required)

Contact Number (required)

Email

Preferred method of contact

REFERRAL DETAILS

Referring Organisation (required)

Referred by (required)

Contact Number (required)

Email

Referral to (required)

How does the client meet the eligibility criteria for the project ticked above?
(Refer to the ‘Services Directory’)

Reason for referral
(Provide some background information about the client and the type of support required)

Additional Information
(Provide any information you believe is relevant to help supporting the client i.e. restriction to access services, language barrier etc.)

I understand that Sandwell Consortium CIC is registered under the Data Protection Act. You have a right to know the information we are keeping about you and how we may share it. The personal Information you have provided will be stored electronically by Sandwell Consortium CIC, and it will only be used as part of the referral process.

I confirm that the information provided is correct and can be shared by the ‘referring organisation’ to Sandwell Consortium CIC as part of the referral process.

Sandwell Consortium CIC has a number of delivery partner organisations who deliver services on our behalf. I confirm that I give consent for my personal information to be passed to Sandwell Consortium CIC, who will share the information with the appropriate delivery partner as part of the referral process. We will only contact you to provide more information about the project or service identified in this form. Under no circumstances will we pass information to any other organisation, neither will we contact you for other sales and marketing purposes. You can view our privacy notice at www.sandwellconsortium.co.uk