Rutland Community Wellbeing Service Referral Form

Privacy Notice

Citizens Advice Rutland collects and holds your personal information. We use this information to:

• Make decisions about your support and advice needs
• Help us to work with you and agree the support and advice you need
• Work effectively with others who may also provide you with support and advice
• Make sure we manage our services effectively

This includes personal characteristics and sensitive information (special category data) relevant for the services we provide. The information we collect may be stored electronically, on paper or a mixture of both. We will not disclose any information provided ‘in confidence’ to anyone else without permission, except in the few situations where disclosure is required by law, or where we have good reason to believe that failing to share the information would put someone at risk.

We need to obtain your consent to store your information and before doing so please read our privacy statement

Do you give consent?*

Your Personal Details

Title*: Name*: Date of Birth*: NI Number: Telephone*: Email Address: Address*: Postcode*: First Language*: Do you require an interpreter?*

Alternative Contact

(for contacting regarding appointment times etc.)

Name: Telephone: Relationship to you: Address:

Support/Service Needs*

(Please tick all that apply to help us identify the best service(s) to meet your needs)

Other:

Source of Income*

Other:

Monitoring Form

(For monitoring purposes please complete all sections. Tick only one box in each section)

Gender*: Ethnicity*: White: Mixed: Asian or Asian British: Black or Black British: Other Ethnic Group: If Other, please specify: Do you consider yourself to have a disability?*

Client Consent

I hereby give permission for information relating to me and my support/advice needs to be recorded and shared by Citizens Advice Rutland, The Bridge, Spire Homes, Age UK and Vista as necessary.

Your information will not be disclosed to anyone else without your permission (unless there is a risk of harm to you/others or criminal activity). Click here to read our Privacy notice.

Do you give consent?*