Self 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

Forename *

Surname *

Preferred name

Address (including postcode) *

Phone number *

Email address *

Date of birth * +

Have you been known by a different name? *

Yes

No

NI number *

Preferred language *

Interpreter or Signer required *

What relation are they *

Emergency contact phone *

Where did you hear about us? *

Details of Applicant’s Mental and Physical Health (e.g. diagnoses, disabilities, etc.) *

Applicant’s Priority Needs (e.g. identification of support required, accessibility requirements, and services needed): Type of service *

Details of needs *

Is support currently provided by any of the following? Please provide details *

Please provide details (contact name, organisation, phone number) *

In which areas is support required? *

Additional information – please DO NOT leave blank: *

I confirm that the information contained in this document is true and includes all relevant information required to correctly assess this referral.

Signature *

Date * +

CONSENT

Under the United Kingdom General Data Protection Regulation (UK GDPR) & The Data Protection Act 2018 it is a requirement to obtain your consent to share information about you with other agencies and organisations who may be involved in providing services to you. You have a right to prevent this and therefore do not have to consent if you do not want your information to be shared. However, it may be difficult to provide you with some of the services you need if you do not give your consent.

Once your referral has been made to the correct agency your information will be managed under that agencies own data protection policy and processes.

I give my permission for agencies to obtain further information from all other relevant agencies which may include, for example, Adult and Community Services, landlords, police, probation, benefits agencies and housing benefit offices.

I understand that this information will only be made available to providers/organisations operating under the Durham Mental Wellbeing Alliance that are able to assist me to obtain the correct level of support and enable me to sustain independent accommodation.

Signature *

Date * +

If obtaining a signature was not possible, TICK to confirm you have the Applicant’s verbal consent

Verbal consent given

EQUAL OPPORTUNITIES – required by Commissioner for funding purposes

We aim to promote equality and inclusion to ensure fair access to the service in line with the Equalities Act 2010. These questions are used to monitor access to the service and are not used to make decisions on eligibility or allocation. We will not discriminate unlawfully and our Equality Protocol is available on request.

How do you define your gender? *

Male

Female

Non-binary

Other Other

Is your gender identity the same as your sex assigned at birth? *

Yes

No

Prefer not to say

Ethnicity/ Nationality *

Sexual Orientation *

Religion/ Belief *

Marital/Civil Partnership Status *

Pregnant or given birth in the last 6 months? *

Yes

No

Prefer not to say

Not known

Do you have a Physical Disability? *

Yes

No

Prefer not to say

Do you have a Learning Disability? *

Yes

No

Prefer not to say

A person is disabled under the Equality Act 2010 if they have a physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on their ability to do normal daily activities.

Do you have a support need around your mental health? *

Yes

No

Prefer not to say

Do you have an Autism Diagnosis? *

Yes

No

Prefer not to say

Are you on the pathway for an exploration of an autism diagnosis? *

Yes

No

Prefer not to say

Do you have a drug and/ or alcohol support need? *

Yes

No

Prefer not to say

Please make sure you have completed all relevant questions and then click the Submit button

Christianity – Catholic	Christianity – Protestant
Islam	Non-religious
Hinduism	Chinese Traditional
Buddhism	Sikhism
Spiritism	Judaism
Other	Not known
Prefer not to say