Partner Referral - Citizens Advice

Please get in touch if your organisation has not referred clients to us before as we will not be able to process your referral
How we use your clients information

To help us advise your client we will use the information you provide in this referral to provide your client with advice and to improve our service and inform our campaigns. If the person you refer wants more detail about their rights and how we use their information they can read our privacy notice on our website.
www.citizensadvice.org.uk/myinformation Privacy policy & cookies - Citizens Advice

How Citizens Advice Use Your Information
Citizens Advice Salford will use the information in this referral to provide the person referred with advice as well as to improve their service and inform their campaigns. The person referred can see more details about their rights and how Citizens Advice Salford uses their information by reading their privacy notice.*
I confirm the above has been explained to the client
Privacy policy & cookies - Citizens Advice
Citizens Advice privacy policy - Citizens Advice

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
Untitled
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

Partner
Referral
Form