DASCAS

Name *

First

Last *

Last

Email

Can we email you? *

Yes

No

Phone *

Can we leave a voicemail? *

Yes

No

Can we text you? *

Yes

No

Date of Birth *

First language (if not English)

Address *

Address Line 2

City

Postcode *

Disability *

Please include any communication/mobility difficulties

How do you want DASCAS to help you? *

What benefits are you getting at the moment? *

What have you done so far? *

Do you live with someone else? *

Yes

No

If yes, please give details

Please tell us any more information about your enquiry or relevant dates (e.g. when your form is due back)

Are you making this referral on behalf of someone else? *

Yes

No

Referrer details

Name *

Organisation *

Phone Number *

Email *

We offer home visits to some clients. Have you experienced any of these issues when working with the person you're referring? *

Inappropriate or threatening behaviour

Hoarding or poor hygiene at home

Drug or alcohol misuse

None of the above

Do you have any other concerns about the safety of us sending a member of staff or volunteer to the client's home? *

Consent *

By ticking this box you're giving consent for us to hold your personal data, including any information you've provided about your health, race or ethnicity, religious or philosophical beliefs, sexual orientation, trade union membership or political opinions. If you're completing the form on behalf of someone else you're confirming that the other person has given consent. You can call us if you or the person you’re referring don’t want to consent or have any questions about how we collect, store and handle personal data.

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