Children's Centre Referral form

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? *

Yes No

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?

Phone Text Email

Preferred contact method

Phone Text Email

Any special contact instructions?

Client Name

First Name Last Name

Client Address

Street Address
Street Address Line 2
City	State / Province
Postcode	Country

Client's preferred phone

Is it OK to leave a message on this phone?

Yes No

Client's other contact number

Is it OK to leave a message on this phone?

Yes No

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.

I agree to the Citizens Advice service recording information about me *

Yes No

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.

I consent to your holding information on my (please tick those you agree to):

Health conditions Ethnicity

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 *

Yes No