Referral Form

Have you already received the benefit forms?*

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*

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 Referral
Please provide any additional information on your reason for referring to DISH for support.*

Please ensure you obtain your benefit form before making a referral to us. Please see the link above for information. Once your application form arrives, please complete this referral form.

If you have not received the benefit form, please contact the Department of Work and Pensions to obtain the forms.

Please enter the return date shown on the front of your form.*

Please ensure you obtain your benefit form before making a referral to us.

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 risk
Please indicate if you have any accessibility, language requirements, or anything else that we should know, i.e. risk factors, family or household risks. If you are unsure, please give us a call.*

How did you hear about us?*

I confirm the information above is accurate and correct.*

Yes