Patient Welfare Advice Service Project referral form - Citizens Advice Wandsworth

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Patient Welfare Advice Service Project referral form
PWAS referral form
Please complete this form to refer your patient to the Citizens Advice Wandsworth Patient Welfare Advice Service.
The patient will be contacted within 10 working days (urgent issues will be prioritised).
If you have any queries, please email swlicb.cawpwas@nhs.net

Client's / Carer's Personal Details
First name *
Last name *
Date of Birth *
How would you like us to address them? (eg, Chris or Christopher) *
Address *
Post code *
Telephone number
Email address
Which of these contact methods will they find acceptable?
Phone
Text (SMS)
Email
Letter
Is it OK to leave voicemail or send SMS?
Yes
No
Does the client require an interpreter? If yes, in what language.
Demographics
Citizens Advice Wandsworth needs the patient’s permission to record and use their personal data, including their ethnicity, religion, health conditions and sexual orientation. We’ll use this personal data to: give advice; help us gather data to improve our service; and support our research in a way that the patient cannot be identified.
We’ll make sure all their information is kept safe in our secure case management system. Please complete the following demographics information with the patient’s permission.
Gender
Male (including trans men)
Female (including trans women)
Non-binary
Other
Not known
Preferred pronoun?
He/him
She/her
They/them
Other
Not known
Sexual orientation
Heterosexual/straight
Gay/lesbian
Bisexual
Not known
Marital status
Single
Married/civil partnership
Divorced
Widowed/separated
Ethnic background
White British
White Irish
Any other White
Mixed: White and Black Caribbean
Mixed: White and Black African
Mixed: White and Asian
Any other mixed background
Chinese
Asian or Asian British Indian
Asian or Asian British Bangladeshi
Asian or Asian British Pakistani
Any other Asian background
Black or Black British African
Black or Black British Caribbean
Any other Black group
Any other ethnic group
Not Known
Religion
No religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Not known
Other religion, please describeOther religion, please describe
Is there anything we need to consider to make the service more accessible? (BSL, hearing aid, registered blind, mobility needs, ie, wheelchair)
Is there anything we need to be aware of to maintain safety? If yes, please give more information (eg, self-harm, suicidal ideation, risk issues, safeguarding concerns or living situation).
Please briefly summarise their current situation and what support they may require from the Patient Welfare Advice Service.
Things to consider: Are they currently on benefits? Do they need a welfare benefits review? Are they experiencing any issues with their benefits or do they have any upcoming changes (eg. benefits sanctions, redundancy, change to working hours) Do they have any important deadlines for benefits forms? Are there also support needs for housing, debt, grants, employment, social isolation, or wider community services.
Referrer's details (or other key professional involved)
Referrer's Name *
Job title (GP, linkworker, other) *
Email address *
GP Surgery *
Carer, friend or family member involved
Carer, friend or family member's name
Relationship to client
Telephone number
Email address
Consent
Yes
No
Has the person consented to their personal information, including their demographic details, being shared with the organisations that operate the Patient Welfare Advice Service? If no, please obtain this information before sending the referral.
Captcha

If you are human, leave this field blank.

You can read our privacy policy to find out how we store and use your personal information or the information of someone you refer to us.

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