Rutland Access Partnership Community Prevention and Wellness Service Referral Form

Complete the form below or if you would like a discussion prior to referral, please contact us.

Referrer’s Details

Client’s Personal Details

Alternative Contact

(for contacting regarding appointment times etc.)

Please tell us about anybody else that lives in the property

Support/Service Needs

(Please tick all that apply to help us identify the best service(s) for the client’s needs)

Source of Income

Needs/Risk Assessment

Known Medical History

History of Substance Misuse?

Housing Needs

Does the client have any other support workers?

Client Consent

I hereby give permission for information relating to me and my support/advice needs to be recorded, processed and shared by, and between, the referring agency and The Bridge, Spire Homes and Citizens Advice Rutland (Rutland Access Partnership) alongside Age UK and Vista with the understanding that this will not be disclosed to third parties without prior consent (unless there is a risk of harm to myself/others or criminal activity).

Monitoring Form

(For monitoring purposes please complete all sections. Tick only one box in each section)

Privacy Notice – Data Protection Act 1998

Rutland Access Partnership, Age UK and Vista collect and hold personal data about service users for whom they provide support and advice. We use this data to:

  • Make decisions about your support and advice needs
  • Help us to work with you and agree the support and advice you need
  • Make sure your accommodation, support and advice is safe and effective
  • Work effectively with others who may also provide you with support and advice
  • Make sure we manage our services effectively

This includes personal characteristics and sensitive information relevant for the services we provide. The information we collect may be stored electronically, on paper or a mixture of both, and we use a combination of working practices and technology to ensure that your information is kept confidential and secure.

We will not disclose any information that you provide ‘in confidence’ to anyone else without your permission, except in the few situations where disclosure is required by law, or where we have good reason to believe that failing to share the information would put someone at risk.

On occasion, we will provide personal information to external organisations who are working with us on a specific project or delivery of specific services. This is done under strict agreements regarding the security and confidential use of all personal data.