Rutland Community Wellbeing Service Referral Form

Complete the form below or if you would like a discussion prior to referral, please contact us.

Privacy Notice

Citizens Advice Rutland collects and hold personal data about service users for whom they provide support and advice. We use this data 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 them 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, and we use a combination of working practices and technology to ensure that your information is kept confidential and secure. 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. As we store sensitive information we need explicit client consent to do so (please see below)

For more information on how we store data please click here.

Referrer’s Details

Client’s Personal Details

Please tell us about anybody else that lives in the property

Support/Service Needs*

(Please tick all that apply to help us identify the best service(s) for the client’s needs)

Needs/Risk Assessment

Housing Needs

Does the client have any other support workers?

Monitoring Form

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

Client Consent

I hereby give permission for information relating to me and my support/advice needs to be recorded and shared by, and between, the referring agency and 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).

For more information on how we store data please click here.