Plus services referral form

Name

This field is for validation purposes and should be left unchanged.

Data protection

I understand the information I provide will be managed in accordance with Data protection legislation and 糖心传媒 privacy notice which is available on our website . All information provided will be held securely and only used for the purpose of assisting you with employment and money advice.

I understand in some circumstances it may be necessary for 糖心传媒 to discuss my personal circumstances and share the information with colleagues in the wider Housing Plus Group. This information will not be discussed with third parties, unless you provide consent, or the law requires us to do so. If you have any questions, you can contact data.protection@housingplusgroup.co.uk, or you can call our customer service centre on 0800 048 8955.

Are you completing this form for yourself or on behalf of someone else?(Required)

For myself

On behalf of someone else

If you are completing this form on behalf of someone else, do you have consent to share their personal data?(Required)

Yes

If you do not have their consent, please do not complete or submit this form.

Date

Referrer details

Name of referrer(Required)

First name Surname

Agency

Phone

Client details

Name(Required)

First Last

Date of birth

Gender

Ethnicity

Address

First line address Second line address Town County Post code

Email address

Can we send an email?(Required)

Yes

Home phone

Can we leave a message?(Required)

Yes

Mobile phone

Can we send a text?(Required)

Yes

When is the best time to call?

Are there any additional communication support needs?(Required)

Yes

Please provide further details if answered yes.

What do you need help with(Required)

Please provide brief details of the advice/support you need and anything else that you think might be useful for us to know:

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