Client Registration Form

Referral Type*

Referral Location*

Which team are you referring into ?

Organisation Name

Organisation Email

Organisation Contact Number

All of the information below is about the person you are referring for support.

If you are referring a friend or family member the questions that ask about 'you' are still about the person you are referring.

Please tell us what information, advice or support is needed?

Please also use the section to provide any other information that we may need to be aware about, such as availibility for contact from us or deadlines for benefit claims.*

Title*

First Name*

Surname*

Gender*

Date of Birth*

Address line 1*

Address line 2

Address line 3

Address line 4 (Town)*

Address line 5 (County)*

Postcode*

Email Address

Can we contact you by email?*

If you do not have an email can we contact you by post?

Main Telephone No.*

Can we contact you by telephone?*

Can we contact you by text message?*

Can we leave a voicemail?*

Can you read English?*

Can you write in English?*

Employment Status*

Marital Status*

Sexual Orientation*

National Insurance Number

Would you be interested in attending any support groups or activity sessions?

Are you an unpaid carer for a friend or family member?

Are you or your partner current/ex-armed forces or did you complete national service?

Do you have a hearing or visual impairment?

Do you have a long-term physical or mental health condition?

Are you over 65 and would you like to find out more about the activities available in your area?

Do you require support with claiming welfare benefits?

To comply with data protection law, Improving Lives Plymouth will only collect and securely store information about you to enable us to provide you with the support you have requested. We will treat the information you provide as confidential and will only share your information with partner organisations if necessary, and other organisations with your permission to help achieve the best outcome for you. Further details about how we use your information can be found by visiting the privacy policy on our website improvinglivesplymouth.org.uk/privacy

I have read the statement above and consent to my data being stored with Improving Lives*

Has the person you are referring consented to you sharing their information with Improving Lives Plymouth?

When a text box is mandatory and must be filled in this will be outlined by a red border upon selecting the field this will then turn to blue which means that you are currently on that field, any fields that are not mandatory will have no border