Make a Referral - Navigate Charity

Please indicate that the client consents to you sharing their information with Wis£rmoney to access the services we provide and that you, as the referring party, have explained to the client and they agree and understand the following information in order to refer to the Wis£rmoney service:*

I Agree

That personal and sensitive information may be provided by you (the referring agency) about the client(s) in order to make a formal referral into the Wis£rmoney service.*

I Agree

That personal and sensitive data will be shared on a need to know basis in order to make an appropriate referral.*

I Agree

That we will confirm to you whether they have engaged with the service or not*

I Agree

That personal information may be kept in a file or on computer. If money and/or debt advice doesn’t proceed, personal data will be destroyed after 2 years. If money and/or debt advice does proceed, a Wis£rmoney member of staff will provide the client with a copy of our Privacy Notice explaining in more detail what will happen to their data*

I Agree

Referrer Details

Agency Name

Your Name

Your Role

Phone Number

Email Address

Best Days and Times to Contact to Discuss

Date of Referral

Please tick here if you consent to receive updates on the project, you can opt out at any time. A copy of our privacy notice is available here: Privacy Notice
Information for the referrer: We will store your contact details for our records. This is kept for 12 years from the date money and/or debt advice is concluded or 2 years if it does not proceed.

Client Details

Client Full Name

Client Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Phone

Mobile

Email

Preferred Contact Method

Phone
Post
Email

Can we leave a message for the client

Yes, text or voicemail.
Yes, text message only.
No.

To enable us to deal with the referral quickly and efficiently, please tick all that apply

Yes as the referrer, I would like to be telephoned before making contact with the client to discuss the referral.
No, I do not want to be contacted.
Yes the client is aware that a Wis£rmoney Adviser will make contact to arrange an appointment
No the client is not aware that a Wis£rmoney Adviser will make contact to arrange an appointment.
Yes as the referrer, you wish to be informed whether the client is engaged with the service or not
No, as the referrer I do not wish to be informed whether the client engages with the service or not.
Yes as the referrer, you need to be present at the initial appointment to support the client
No, I do not need to be present at the initial appointment to support the client.

To enable us to deal with the referral quickly and efficiently, please tick all that apply.

Risk Assessment, you must answer the following questions by ticking all that apply otherwise we will not be able to accept the referral.

Yes there are safety issues about visiting alone or being alone with the client
No there are no safety issues about visiting alone or being alone with the client.
Yes I, or anyone in my agency visits the client alone.
No, I or a member of my agency have never visited the client alone.
Yes there are safety and other risks that we need to be aware of.
No, there are no safety or other risks you need to be aware of.
Yes if required, I would attend a joint visit with the client.
No, I cannot attend a joint visit with the client.

If any risks are identified the Wis£rmoney Adviser will contact you to discuss.

Client Advice / Support - Please tick the options that apply.

Yes the client referred will continue receiving advice/support from me, the referring agency, while working with the Wis£rmoney service.
No the client referred will not continue to receive advice/support from me, the referring agency, while working with the Wis£rmoney service.
Yes Wis£rmoney can refer the client to you, the referring agency, upon case closure from the Wis£rmoney advice service for ongoing advice/support.
No, Wis£rmoney cannot refer the client to me, the referring agency, upon case closure from the Wis£rmoney advice service for ongoing advice/support.

CAPTCHA

Referral Form

For agencies referring

REFERRING YOURSELF OR A FRIEND OR FAMILY MEMBER