SHARING TIME REFERRAL FORM Please return to: Age UK Cambridgeshire Sharing Time 2 Victoria Street CHATTERIS Cambs PE16 6AP T: 01354 691898 F: 01354 696119 E: dee.potter@ageukcap.org.uk Client ID No

Date of referral

CLIENT DETAILS If completing form electronically please tab through each section. Only complete first page for the referrer.
Title
Surname
First Name
Known As
Telephone No
Home Address
Current Address (if different)
AREA
Marital Status
Gender
Date of Birth
Religion
Ethnic Group
Has client given permission for this referral?
NEXT OF KIN DETAILS
Name
Relationship
Address
Telephone No
REFERRER DETAILS
Name
Relationship
Address
Telephone No
MEDICAL DETAILS
Medical condition/history
Critical Information
REASON FOR REFERRAL (please provide as much information as possible)
What contact have you had with this person? Face to face or telephone?
Are there known risks to lone workers?	IF YES PLEASE STATE THE RISK

CONTACT IN CASE OF EMERGENCY	NAME	ADDRESS	TELEPHONE NO
FAMILY CONTACT
EMERGENCY CONTACT/KEY HOLDER
DOCTOR
OTHER

AGE UK CAMBRIDGESHIRE STAFF USE ONLY:

ANY OBVIOUS RISK FACTORS OBSERVED AT ASSESSMENT VISIT	ACTIONS REQUIRED TO REDUCE THIS RISK
CLIENTS INTERESTS AND HOBBIES
ANY SPECIFIC REQUESTS FROM CLIENT	REFERRAL TO LIBRARY SERVICE Y/N
ADDITIONAL INFORMATION/HELP REQUIRED
DO YOU HAVE ANY COMMUNICATION NEEDS?

I am signing to acknowledge that I understand that Age UK Cambridgeshire will hold and retain this information about me in a confidential manner.

Sharing Information

Many Age UK Cambridgeshire services are funded by Cambridgeshire County Council. In order to meet government requirements, the council has to show how many people it supports directly or indirectly. It would help them to do this if you would be willing to let us share your name and address with the County Council. The Council adheres to the principles of the Data Protection Act and so the information will be used only for the purpose intended and will not be shared with anyone else, and destroyed when no longer needed. Please contact Sam Burton, Human Resources, Age UK Cambridgeshire, 2 Victoria Street, Chatteris Cambs PE16 6AP if you require any further information.

AGREE____ __________________ NOT AGREED ______ _________________

I am signing to acknowledge;

Age UK Cambridgeshire will retain this information about me confidentially

Age UK Cambridgeshire files are open to audit and inspection by the commissioners of the service, where appropriate

My details will not be referred to others without my expressed permission, other than in exceptional circumstances.

CLIENT SIGNATURE____ _________________________________ DATE __ _______

ORGANISER SIGNATURE___ ______________________________ DATE __ _______