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What’s the referrer’s email address?*
What is the surname of the person you are referring?*
What is the first name of the person you are referring?*
Please tick the two legal conditions you have used to satisfy the processing of personal and special category information about the person you are referring
Consent*
Legitimate interest*
Legal obligation*
Performance of a contract*
Vital interest*
Public interest*
Other, please specify
Is the person eligible for advocacy from CASBA? (If you answer "no" to any of the next three questions, then please contact us on 0121 475 0777 to see if we can direct you to a more appropriate service.)
Is the person you are referring aged 18 or over?*
Does the person you are referring have a learning disability?*
Does the person you are referring live in South Birmingham?*
Information about you, the referrer
Referrer's name?*
Referrer’s address*
Address line 2*
Town*
Referrer’s postcode?*
Referrer’s phone number?*
How did you hear about CASBA?
Information about the person you are referring
What is the date of birth of the person you are referring?*
What’s the address of the person you are referring?*
Postcode*
What’s the phone number of the person you’re referring?*
Please explain the presenting issue and why advocacy support is being requested.*
Do you know what a hospital passport is?
Do you have a hospital passport?
Would you like help to get a hospital passport?
Do we need to be aware of any risks when meeting with the person you are referring?
Verbal abuse
Aggressive or intimidating behaviour
Problems with working with either female or male staff
Non-cooperation with staff
Issues around mental illness
Issues around drug and alcohol abuse
Issues around criminal or anti-social behaviour
Financial abuse
History of rape or sexual assault
Accidental fire setting/arson
Lone working considered unsafe
Problems in working in a group (own vulnerability or risk to others)
Self-harm
Please give further details for any risks noted, or any others not listed above:
Who is at risk?
We require the following information for monitoring purposes you can choose not to give an answer. However, we can use this information to ensure we are reaching all those we need to.
What is their ethnic background?
What is their gender?
Do they speak English?
Can they communicate verbally?
Can they read and write?
What is their age?
Do they have a disability other than a learning disability?
What is their religion?
What is their sexual orientation?