Duty to refer application form

Fields marked with * are required
Customer Information
1. Name*
2. Address*
3. Telephone Number*
4. Email Address*
5. Date of Birth (DD/MM/YYYY)*
Reason for Contact
1. Reason for Referral*
2. Discharge Date (DD/MM/YYYY)
  If hospital/prison release please provide discharge date
Support Worker Information
1. Support Worker Name*
2. Contact Email*
3. Contact Phone No*
Referring Agency Information
1. Referring Agency*
2. Referring Officer*
3. Officer Contact No*
4. Officer Email*
Declaration
1. I can confirm that I have the named customer's consent to complete this duty to refer application.
  I understand that by checking the declaration box it is classed as my electronic signature and is the legally binding equivalent to my handwritten signature.
2. Signature
Are you completing this form on behalf of someone else?*
1. Yes
2. No
Assisted service details
1. In what capacity are you completing this form?
  
  CC Staff
  
  Agent/Solicitor
  
  Relative/Friend
  
  Carer
  
  Other
2. Name of person completing this online form
3. Email of person completing this form
Privacy statement

Breckland Council is collecting this information, via this form, in order to perform this service or function, and if further information is needed in order to do so, you may be contacted using the details provided.

In performing this service, the Council may share your information with other organisations or departments, but only when it is satisfied that it is necessary to perform a public task, or to exercise its statutory duties to do so.

The Council may also share your personal information for the purposes of the prevention, investigation, detection, or prosecution of criminal offences, but will not share your personal information, or use it for any other purpose, unless provided for by law.

More detailed information about the Council's handling of your personal data can be found in our privacy policy.

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Duty to refer application form

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Duty to refer application form

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