Extra Mile Referral

Step 1 of 3

33%

Person completing this form

Referrer name

First Last

Job title

Organisation

Referrer phone

Referrer email

Should first contact be made with the client or referrer?

Referrer

Client

Would you like to be kept updated?(Required)

Yes

Are other agencies Involved? If so please tell us about them.

Person this form is about

Name

First Last

Phone

Are we able to send a text to this number?(Required)

Yes

Date of birth

DD dash MM dash YYYY

Address

Street Address Town/City Postcode

When is the best time for us to get in touch?

Are we able to leave a voicemail?(Required)

Yes

National Insurance Number

Are there any access issues? (e.g. mobility issues, needs a BSL interpreter etc)(Required)

First/Second Language/Ability (e.g. understanding English)

Disability / Health Problems?

Enquiry

Enquiry type. Please select.(Required)

Brief description of the advice needed(Required)

The client has agreed to the referral and for their data to be shared with Citizens Advice Flintshire.

Yes

I confirm that my client has agreed to the referral and for their data to be shared with Citizens Advice Flintshire. My client is aware that outcomes can be shared back to my agency unless specified otherwise.

The client is aware that Citizens Advice Flintshire will use their information.

Yes

I can confirm that my client is aware that Citizens Advice Flintshire will use their information in order to provide them with advice as well as to improve our service and inform our campaigns. My client is aware that if they want more detail about their rights and how Citizens Advice Flintshire will use their information they can read our privacy notice on our website - https://flintshirecab.org.uk/privacy-policy/

Get Advice

Get Involved

About Us

Extra Mile Project