Children's Centre Referral form

Please note that due to summer holidays / annual leave, there will likely be a delay of up to two months before the caseworker can contact your referral. Where urgent assistance is required, in addition to completing this referral form, please advise the person you are referring to call our Adviceline. To find the phone number for your Local Citizens Advice, go to Citizens Advice Devon and scroll down to where it says Your Local Citizens Advice Office

We may be able to contact the client in response to this referral within a few days, but it may take us a few weeks, depending on the volume of referrals. Where urgent assistance is required, in addition to completing this referral form, please advise the client to contact Citizens Advice as soon as possible on 0808 278 7997.

Name of person referring the client*

Contact number of person referring the client*

Email address of person referring the client*

Children's Centre Area*

Children's Centre Subarea Exeter*

Children's Centre Subarea Eastern Devon*

Children's Centre Subarea Northern Devon*

Children's Centre Subarea Southern Devon*

Has the client given you permission to pass on their details?*

YesNo

You need to obtain the clients permission to record their details before you can continue with the rest of the form.

How can we contact the client?

PhoneTextEmail

Preferred contact method

PhoneTextEmail

Any special contact instructions?

Client Name

First NameLast Name

D.O.B

DOB

Client Address

Street Address

Street Address Line 2

CityState / Province

PostcodeCountry

Client's preferred phone

Is it OK to leave a message on this phone?

YesNo

Client's other contact number

Is it OK to leave a message on this phone?

YesNo

E-mail

Brief description of issue

Client consent

At Citizens Advice we must ask for your consent to record, use or share personal information. This form is used to do that. For more information, please see the Citizens Advice Devon privacy policy.

Permission and consent

When we record and use your personal information we:

only access it when we have a good reason
only share what is necessary and relevant
don't sell it to commercial organisations
We need to record information about you to help with your enquiry. We have a legitimate interest to do this.

Special category personal data

We need your consent to record and use your special category personal data

We need your explicit consent to use some information, including your ethnicity, religion, health conditions and sexual orientation.

If you agree, we'll use this information, which is known as 'special category personal data', to:

give you advice
help us gather data to improve our services
support our research in a way that you can't be identified

We'll make sure all your information is kept safe in our secure case management system.

Permission and consent

When we record and use your personal information we:

only access it when we have a good reason
only share what is necessary and relevant
don't sell it to commercial organisations

We need to record information about you to help with your enquiry. We have a legitimate interest to do this.

I agree to the Citizens Advice service recording information about me

YesNo

Special category personal data

We need your consent to record and use your special category personal data

We need your explicit consent to use some information, including your ethnicity, religion, health conditions and sexual orientation.

If you agree, we'll use this information, which is known as 'special category personal data', to:

give you advice
help us gather data to improve our services
support our research in a way that you can't be identified

We'll make sure all your information is kept safe in our secure case management system.

Does Citizens Advice have consent to record the information you are providing?*

Yes

I consent to your holding information on my (please tick those you agree to): Please Note: If you have mentioned either a client's health condition or ethnicity above then you must obtain the client's consent to submit this referral form

Health conditionsEthnicity

Can we contact you for feedback?

We want to make sure our service meets your needs. To help us understand how we're doing and to improve our service, we may want to contact you at a later date to ask for your feedback. Sometimes we need a trusted research organisation to help us do that.

We'll decide who we contact for feedback based on the services you used and the advice area. We may also use your special category data so that we hear from different groups.

I agree to Citizens Advice selecting me for feedback using my information and contacting me*

YesNo

We are registered with the Information Commissioner's Office under ZA151105 and will process your personal data in accordance with the General Data Protection Regulation and Data Protection Act 2018. Please refer to our online Privacy notice at https://www.cabdevon.org.uk/about-us/privacy-statement-2/ for more information on how your personal data will be processed and stored.