Online Referral – PCAS Shropshire

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- Referral Form
  - Download Referral Form PDF
  - Download Referral Form Word Doc

Home
Who we are
What we do
Support us
News & Events
- News
- Events
Contact PCAS
- Contact us
- Referral Form
  - Download Referral Form PDF
  - Download Referral Form Word Doc

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 2, Old Station Building, Oswald Road, Oswestry, Shropshire, SY11 1RE

Contact

01691 658008
07877 516243
simon@shropshirepcas.co.uk

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

Title *

First Name *

Surname *

Date of Birth *

Address *

Home Telephone Number *

Mobile Number

Date of Referral *

Clients Disabilities (please select all that apply) *

Physical
Sensory
Mental Health
Learning Disability
Acq Brain Inj
Over 65
MS
Other

Issues (please select all that apply) *

Adaptations / Equipment
Child Protection
Consumer Goods / Services
Correspondence
Debt
Discrimination
Financial Services & Capability
Housing
Legal
Meeting
Mental Health
Residential Nursing Home
Relationships & Family
Social Care
Safeguarding

How Can We Help? *

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:

Consent to referral - We need approval to show that people understand and agree to this referral. Also that you agree to PCAS holding personal information about you. If the person being reffered is not able to understand these things, the referrer must acknowledge that they are providing this information in the person's best interests. *

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

Phone

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