Refer to Access Dorset – Access Dorset

Please read before taking a referral: The information you are providing us is confidential within our organisation. However, there may be times we have to breach confidentiality without your permission. This is in instances where we believe there could be an immediate risk to someone’s life or risk of serious harm or there is another safeguarding concern. Please continue if you’re still happy to continue with the referral.

Name *

First

Last

Address

Phone number

Email *

Preferred method of communication

e.g. phone, email etc.

Ethnicity

Emergency Contact

Please include name and telephone number

Date of birth

How did you hear about Access Dorset

Are you disabled or do you have any health conditions that we should know about?

Please include any access requirement or allergies.

How did you hear about Access Dorset?

Please tell us about any short term/long term goals.

Please tell us about your availability

How would you rate your confidence in volunteering or joining in on activities at Access Dorset?

Please rate your confidence level between 1 and 5, 1 being not very confident, 5 being very confident.

Do you have any other comments, questions or concerns?

Referrer Information

Please include name, organisation and email or phone number.

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