Agency Referral Form

DATA PROTECTION
By submitting this form you will be agreeing to offering personal information. This means that in accordance with the Data Protection Act 1998 we have a responsibility to keep this information safe & confidential. Information supplied on this form, specifically ‘your name & contact details’, will be retained on a confidential database used for the purpose of administration to compile a delegate list for mailing out either electronically or by hand (as chosen by you).

* Details held are secure: safe from unauthorised access, and kept safe from damage or loss.

* We are likely to contact you in the future to ensure that your details are up-to-date and accurate.

* We will only keep these details as long as you agree and for as long as is reasonably necessary. Either upon your request or at a reasonable time we will ensure that we dispose of your information securely.

Name, relationship & contact details of the person making the referral:*
Name, Address & phone number of the person being referred:*
Please provide us with a brief outline of why this person is being referred:*
Does this individual have any specific needs regarding accessibility? or if you consider there to be any risks involved in working with this individual can you please provide us with specific detail*
Can you please confirm that the person being referred is aware and has given consent to make contact with us*
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