Example form – Humankind

Example form

This is a test referral form. Data entered into this form will not be recorded or used for real referrals. If you are referring someone else, please fill in their details for each question other than where "the referrer" is mentioned.

Example referral form
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Step 1 of 3
Are you making this referral for yourself or someone else?
Name of person being referred
Sex (at birth) of person being referred
We are asking this information so we can tailor support to your individual situation.
Do you have a fixed abode/address?
Please provide a contact phone number, such as a home or mobile number so that we can contact you.
Is there another number we can reach you on? We will use this in case we cannot reach you on your primary phone number?
How would you like us to keep in touch with you? We will use your preferred communication to send you updates such as appointment reminders.
Reason for referral
We need to know this information so we know what type of support you will need from us. Examples of opiates include heroin and morphine. Examples of non-opiates include cocaine, ketamine and cannabis.
We ask this as everybody's goals are different and we can tailor support to what you want to achieve.
It may not be possible to assign you a worker of your preferred gender, but if you do have a preference please let us know.
Do you have any communication needs?
We ask for this information so that we know how best we can communicate with you and if any extra assistance will be required.
We are asking this question so that we can assess how best we can support any extra health needs you may have.
We are asking this question so that we can assess how best we can support any extra health needs you may have.
Do you have a current driving licence?
We are asking this question so we know if you are able to access service locations which may not have ideal public transport links.
Please read the privacy script at the bottom of this page and let us know when you have done so by checking the correct option
We need to ask this so that we know you are making an informed choice to access our support. If you are referring someone else, this must have been read to them and understood.
The next stage of the form focuses on more personal questions. Are you happy to proceed?
It is your choice whether you answer 'Yes' or 'No'. If you answer 'No', your assigned support worker will still need to ask these questions at your first appointment. If you begin to fill out the rest of the form and change your mind about answering the questions, you can click submit without completing everything and we will follow these questions up with you at a later date.

Please read the following privacy script

This project is part of a charity called Humankind.

Our top priorities are your safety and helping you achieve your goals with us. To do this, we need to keep some information like your basic contact details and more sensitive information like your health details. This is called a “legitimate interest” to use your information.

We keep your information safe and only share it with others if there is a good reason. Most of the time we ask your consent before we share, and we will complete our consent process with you during your first appointments with us. Occasionally, we may need to share your information without seeking your consent if we are worried that you or someone else could be in danger. This is called safeguarding and is a UK law that all health and social care organisations must follow. We will usually be able to tell you what we have shared and to whom. We will provide a factsheet with examples when we meet.