Partner Referral - Citizens Advice

Partner Referral Form - New partners must contact us before referring a client or your referral will not be accepted
Thanks for contacting us. Please note that we need to record information about your client to help with their enquiry. This is the information detailed on our enquiry form as "Client Personal Details". We have a legitimate interest to this and will only access it when we have a good reason, only share what is necessary and relevant and don’t sell it to commercial organisations.

We need your client's explicit consent to use some information, including their ethnicity, religion, health conditions, sexual orientation, trade union membership and political opinion.

If they have given you consent to share this, we’ll use this information, which is known as ‘special category personal data’ to:
- give them advice
- help us gather data to improve our service
- support our research in a way that they can’t be identiﬁed
Privacy

We’ll make sure all your client's information is kept safe in our secure case management system. To find out more read our privacy policy.

Please note that we can only deal with enquiries from residents of Salford or those with a Salford GP so please ensure you give us your client's full address details or details of your GP. If neither of these apply to you then we won’t be able to respond. If this is the case then please visit the Citizens Advice site for details of your local service.

Data Purpose
My client has been informed how Citizens Advice Salford holds their data and the purposes they use their data for: the provision of advice, to gather data to improve their service, and to support their research in a way they cannot be identified. I have shown the client Citizens Advice Salford's privacy policy if required.*
I confirm the above has been explained to the client
Special Category Data
If you are sharing any special category data about your client ( for example; ethnicity, health condition, religion, sexual orientation or Trade Union membership) please confirm that they have given you their consent*
Yes, I can confirm that my client has consented to you holding special category data

If you are a health professional please complete below as appropriate
Has a health professional issued an SR1 certificate (this replaces the Ds1500, and is a statement that their patient has a severe and progressive disease and as a consequence of that disease, it would not be a surprise if their patient were to die within 12 months) for the client?*
- Yes
- No
Has the SR1 been completed by you*
- Yes
- No
Please provide, name, role and contact number of the health professional who has completed it below.*
Email of health professional who has completed it
If yes, has the client been made aware of their prognosis or life expectancy ?
- Yes
- No
Do you recommend we contact another person who can assist or represent your client in the advice process? For example due to your client being unwell, undergoing acute treatment or care, or some other substantial wellbeing reason.
- Yes
- No
If yes, please provide:
Contact name*
Telephone*
Email*

Client Enquiry
More details about your enquiry
Are there any time limits or key dates that we need to be aware of (for example deadlines to challenge a decision or submit a claim form)?
Time limits - If you feel that your client needs to be contacted as a matter of urgency please provide details.
If your client has any communication difficulties that we should be aware of please let us know here, we may need to contact you further if this is the case

Documents
If you would like to share any documents please do so: here (opens in new window).

Please ensure that you have read the information above on Special Category Data before uploading any documents on behalf of your client.
Are you uploading documents such as a SR1 with this referral?*
- Yes
- No
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Phone
This field is for validation purposes and should be left unchanged.

Partner Referral Form