Let us know how to get back to you.
Please remember to provide at least one way to contact the client.
Please tell us a little about the case by completing the below.
Please briefly describe the primary issue you would like us to look at? *
Please add any additional information to help us allocate the right help for the client (e.g. literacy or language barriers, digital help, physical or mental health problems):
Please set out below any time limits involved in this case and cause:
Is the client in dispute with another individual? *
--- Yes* No
*We will need to contact you for more information before we proceed with the referral.
Has the client presented any behaviour that is contrary to the well-being of staff? *
--- Yes** No
**We will need to contact you for more information before we proceed with the referral.
Please confirm the client is aware of and has agreed to this referral? *
--- Yes No***
***We cannot accept referrals without the clients knowledge or agreement. Please speak to the client then complete this form.
Would you like to know the outcome of this referral?
--- Yes No
We will ask the clients permission to provide feed back to you.
I agree for Citizens Advice Swindon to store the information I have provided in accordance with their privacy policy. *