Referral Form

Name of person Referring

Your email address

Please enter the referral's email address.

Your contact number

Your Organisation or Service (If you are referring from a GP Surgery please include the name of the surgery)

Name of person needing advice

Your name

Client address including full postcode

Client email address

Client number

Client date of Birth

Area of advice needed

Reason for referral

Please give as much information as possible to demonstrate the referral is within the scope of our Service.

Any deadlines? Note extensions on deadlines remain individual responsibility until we make contact.

Does you client have any access requirements?

Please give details below if your client has any access requirements such as an interpreter, level access etc

Please tick if to your knowledge this person is in any of the following groups (tick all that apply)

I have permission to refer this client and the client consents to being contacted via the contact information provided. (required)

I understand that you will attempt to contact the client a maximum of 3 times (required)

I understand that you will be unable to provide feedback on this referral without the clients written consent to provide this information. This can be sent to enquiries@communitylawservice.org.uk. Please allow at least 4 weeks before contacting for feedback. (required)

The client is prepared to discuss their full financial situation when obtaining advice (required)

Please avoid sharing sensitive data such as passwords or credit card info in this form. This is not a secure login or billing page to share that data.