Agency/Carer Referral Form

Data Protection Statement

In order to help us deliver efficient services and to manage your relationship with us, we need to collect relevant personal details from you. In the first instance Home Group Ltd will receive your referral on behalf of DMWA. Home Group Ltd will comply with the General Data Protection Regulation and Data Protection Act 2018 when dealing with personal data. This means that your personal data will be processed in accordance with the law. Please note in some circumstances we may share your personal data with external third parties. For more information on how we process your personal data, including on data security, data retention and lawful processing bases, please access our full privacy notice at: www.homegroup.org.uk/Privacy-Policy

Details of referral agency

Organisation name *

Individual name (referrer) *

Organisation address (including postcode) *

Phone number *

Email address *

How long have you known the applicant *

Has consent been received for referral *

Yes

No

Where did you hear about us? *

Details of person being referred

Applicant's forename *

Applicant's surname *

Applicant's preferred name

Applicant's address (including postcode) *

Phone number *

Email address *

D.O.B * +

Have you been known by a different name *

No

Yes (please state name) Yes (please state name)

Interpreter or Signer required *

No

Interpreter required

Signer required

Both required

Emergency contact name

What relation are they

Emergency contact phone

GP Surgery Name *

GP Surgery Contact Number *