Rutland Community Wellbeing Service Referral Form

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.

Please ask your client to select one of the options below after reading this privacy statement to give their permission for us to hold their information.*

Referrer’s Details

Name*: Job Title*: Agency*: Telephone*: Email Address*: Date Referred:

Client’s Personal Details

Name*: Date of Birth*: NI Number: Telephone*: Email Address: Address*: Postcode*: Communication Needs: How would the client like to be contacted?" Does this client require anybody to be with them at the assessment? (if yes please give details)*: Details of person:

Please tell us about anybody else that lives in the property

Name: Relationship to client: Date of birth (if under 18): Name: Relationship to client: Date of birth (if under 18): Name: Relationship to client: Date of birth (if under 18):

Support/Service Needs*

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

Other: Please give further details to the support needed:

Needs/Risk Assessment

History of violence: Additional info: Recent Major Life Changes (e.g. bereavement, relationship breakdown, ill health etc.): Are you aware of any risks to staff from the client or anyone in the household? (if yes please give details including any risk posed by the property, environment and pets)*: Additional details: Any known disabilities/physical conditions/mental health issues or emotional triggers:

Housing Needs

Housing situation: Rent Arrears (please state amount, if any): Has the client recieved any of the following:

Does the client have any other support workers?

Name: Agency: Job Title: Telephone: Name: Agency: Job Title: Telephone:

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: Does the client consider themselves 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, 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.

Do they give consent?*