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Please identify if you are making a self-referral or as a professional.*
Client Information
Please provide the following information about the person requiring support.
Title*
First Name*
Last name*
Date of Birth*
Email
Address 1*
Address 2
Town/City*
Postcode*
Home Phone Number*
Mobile Phone Number
Preferred Method of Contact*
Ethnicity
GP Surgery
Nature of Disability/Medical Condition*
Reason For Referral
Benefit support required *
Are you already in receipt of any benefits?*
If yes, please let us know which benefits you are in receipt. Please provide details of any benefits you are currently receiving or applying for.*
Reason for ReferralPlease provide any additional information on your reason for referring to DISH for support.*
Have you already received the benefit forms?*
If you have not received the benefit form, please contact the Department of Work and Pensions to obtain the forms.
If yes, what is DWP return date shown on the form?
We may not be able to arrange an appointment before the deadline date, however, you are able to obtain an extension to the deadline by contacting the Department of Work and Pensions
Are you able to complete the form over the phone?Would you be happy for a caseworker to carry out your appointment over the phone using a dummy form for you then to copy?
Specific requirements and riskPlease indicate if you have any accessibility, language requirements, or anything else that we should know, i.e. risk factors.*
How did you hear about us?*
I confirm the information above is accurate and correct.*
Organisation Referral Information
Organisation name
Your name
Your contact email
Professional telephone number
I confirm I have consent from the individual to make this referral
If applying for Disability Living Allowance
Child’s name
Child’s date of birth
Child's disability/medical condition