Online Referral – PCAS Shropshire

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  - Online Referral

Home
Who we are
What we do
Support us
News & Events
- News
- Events
Contact PCAS
- Contact us
- Referral Form
  - Online Referral

Please use the form below to refer yourself or someone else for our services.

If you would prefer, you can download and print the referral form here. Please return the completed form to the address below.

Address

PCAS
Suite 1, The Willow Tree, Willow Street, Oswestry, Shropshire SY11 1AJ

Contact

01691 658008
07877 516243
simon@shropshirepcas.co.uk

We are a free to use, 100% independent, impartial and confidential advocacy service.

Title *

Name *

First

Last

Date of Birth *

Permanent Address *

Home Telephone Number *

Mobile Number

Email Address

Current Address (if different from above)

Date of Referral *

Clients Disabilities (please select all that apply) *

Physical
Sensory (Sight)
Sensory (Hearing)
Mental Health
Learning Disability
Acquired Brain Injury
Dementia/Alzheimer's
Multiple Sclerosis
Autistic Spectrum
Older Person
Other

Issues (please select all that apply) *

Accessing other services
Adaptations / Equipment
Care Issues
Child Protection
Complaints
Confidence Building
Consumer Goods / Services
Correspondence
Debt
Decision Making
Discrimination
Employment
Filing Paperwork
Managing Finances
Form Filing
Housing
Legal
Non-Instructed Advocacy
Reading Post etc
Relationships & Family
Safeguarding
Social Care Issues
Support in Meetings
Utilities

Any Further Information *

When do you need this help? (are there any deadlines or important meeting dates?)

Name of Referrer *

Contact Telephone Number *

Mobile Number

Your Job Title

Your Email address

Organisation *

Social Services
Medical
Carer
Self
Health
Family
Other

Is there any known risk to our workers? *

Yes
No

If Yes to the above please detail here:

Declaration - In making this referral, I declare that: I wish to request Independent Advocacy support from PCAS and I understand that client information will be stored safely on a computer *

I Agree

Consent from the person being referred (leave blank if the person does not understand) - You will be required to give consent about the information we hold about you on our first meeting with you via our consent form before we can act on this referral. Should you NOT give consent, we will be unable to work with you.

I Understand

Consent from the referrer (leave blank if self referral) - I would like PCAS to do this work. They can keep and put on file information about me. This information is to be kept confidential unless i agree for it to be shared. If the client has not understood the above, I am providing this information in the person's best interests and agree that they are aware of this referral and have consented to information about them being stored by PCAS.

I Agree

Email

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