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Thank you for contacting Richmond AID about your query.
If you need help with completing your query please contact us on 020 3393 7011. Please see our privacy statement at the end of this form.
Consent - Please note you must have consent from the client to make this referral to Richmond AID. If you do not have consent it may impact the level of support we can provide. *
Please tell us why you are making the referral (please give as much detail as possible)
Please tell us the name of the organisation you are referring from and give your contact details.
Please give the details of the person you are referring
Title (Mr, Ms, Mrs, Dr)
First name(s)*
Surname*
Address line 1*
Address line 2
Address line 4 (Town)*
Address line 5 (County)
Postcode*
Mobile Telephone No.*
Home telephone no.*
Emergency Telephone No.
Email Address (Main)*
Main Disability*
Date of Birth
Gender
Immigration Status
Ethnic Group
Religious Group
Marital Status
Sexual Orientation
Communication needs
Language or sign language interpretation needed?
Contact preferences
Housing situation
How many people are in your household?
Are you a disabled person living with carer?
Employment situation (for benefits clients)
Social care situation
Name of your GP Practice
Privacy statement
We ask for your personal information so we can help you and we record it on our database. We will treat is as confidential and only share with other organisations with your consent.
You can withdraw your consent to be on our database or have your information updated at any time (call 020 8831 6070 or email advice@richmondaid.org.uk ). You can stay anonymous and we'll record information about your problem making sure you're not identified, but this may impact how well we can support you. Third parties such as the assessors of the Advice Quality Standard may require access to client records for quality auditing purposes. You have the right to opt out from this process if you wish
For more information about how we manage data please see our Privacy Notice on the Richmond AID website www.richmondaid.org.uk