COMMUNITY BUILDER SCHEME

Creating Thriving Local Communities

COMMUNITY ENGAGEMENT REFERRAL FORM

FOR THE SOUTH UTTLESFORD COMMUNITY BUILDER SCHEME

Please fill this formas much as you can and email to . Alternatively, you can post it to: Community Builder Scheme, CVSU, The Old Police Station, 45 Stortford Road, Great Dunmow, Essex CM6 1DQ - please mark your envelope as ‘Private and Confidential’. We can also take referrals over the phone on 07841 632085.

Our Community Builder will meet a referred person to discuss the service with them.

PERSONAL DETAILS
Full Name:
Date of Birth:
Postal Address:
Post Code:
Contact Number:
Email Address:
Preferred contact method:
Name and address of the GP Surgery:
IN CASE OF EMERGENCY (ICE) CONTACT DETAILS
Name:
Relationship:
Phone number:
ADDITIONAL INFORMATION
Do you have any specific requirements relating to culture, gender, religion, disability or other? If yes, please specify:
Our Community Builder might be able to offer a home visit, so please provide any hints on finding the address (if difficult to find). Are there any access orparking restrictions we should be aware of?
Are there any health or behaviour factors that we should be aware of prior to the initial meeting? Please include details of any impairment/s.
CURRENT SITUATION
Is there currently support in place from any other agencies, family of friends?
If yes, please provide details:
Can we contact those mentioned above to obtain details tosupport your referral?If yes, please provide details below:
WHAT ARE YOUR HOBBIES AND INTERESTS?
(please tick all relevant boxes)
Animals/pets / Knitting/sewing / Arts
Books/reading / Music / Social Media (Facebook, etc.)
Dancing / Photography / Fishing
Gardening / Sports / Nature
History / Theatre / Fitness
Writing / Crafts / Walking
Cooking / Painting / Birdwatching
Floristry / Socialising / Baking
Pottery / Board Games / DIY
Nordic walking / Bingo / Bowls
Other (please specify):
AREA OF SUPPORT YOU WOULD LIKE TO RECEIVE
(please tick all relevant boxes)
Leisure/ Social Activities / Loneliness
Neighbour Relations / Social Isolation
Volunteering / Community Engagement
Other (please specify):
CONSENT TO ACCESS AND SHARE INFORMATION
Please read/notecarefully andthensignand datetheform.Ifyou have concernspleasediscussthemwiththepersonworkingwith you. You can note any limit/restrictions in the box ifappropriate
  1. Iagreethat the person making or taking the referral may check with other services and professionals for information about me that helps make a decision about this referral, and so that I receive the right support.
  2. Iagreethat personalinformationaboutme maybe sharedwithCVSU’s research partners Broome Gekoski Limited, to help evidence the effectiveness of my involvement with this service, during and after myinvolvement.
  3. IunderstandthatI have the righttorestrictwhatinformationmaybe shared and with whom.
  4. I consent toCVSU photographing or videoing me/my home/garden to promote the work of the organization.
IunderstandthatImaywithdrawmyconsenttoshare information atanytime.
In some cases we may share information without consent in order to safeguard the vulnerable, to prevent crime and/or if ordered by a Court.
Information I do not want to be shared:
Signed Date
REFERRER DETAILS (no need to fill in if you’re self-referring)
Name
Relationship
Organisation (if applicable)
Phone number
Email address
Reason for referral
Also referred to

Thank you for completing this form. If there is anything else you would like to discuss, please contact the Community Builder team on 01371 878400.

FOR OFFICE USE ONLY
Date referral initiated
Date referral form received
Referral number
Data entered by

THIS SECTION TO BE LEFT WITH/KEPT BY THE PERSON BEING REFERRED

FrequentlyAsked QuestionsaboutInformation Sharing

Why we share personalinformation - Sharing personal information helpsustowork togethertosupportindividuals, their families and carers. But,itisimportanttorememberthat ifyou don’t letusshare yourinformation,thiscould delayor preventyoufromgettingthe help you need.

Ichoosewhat personalinformationisshared aboutme - Mostofthetime we will tell you whatinformation we mightneedto passonandwho we need to passit on to. Thetypesofinformationto beprocessedmayinclude:Name, DateofBirth,Gender,Address,and relevant informationto inform assessment.Ifthere issomething thatyou don’twantustopasson aboutyou then wewon’t.Please tell theperson working with you.

Sometimeswe have toshare personal information aboutyou withoutasking yourpermission,forexample:

•Ifwe are worried aboutthe safetyofa child, young personorvulnerable adult;

•Ifwe think thatacrime may be prevented orfoundout bysharingit;or

•Ifa court orderismadein criminal orlegal cases

Isayno

•You can askusnottopassyourpersonal information toanyone else at anytime

•You can saynoatfirst.You can alwayschangeyourmind lateron

•Orifyou sayyesyou can also changeyourmind later on

The benefits of sharing your personalinformation

•Itwill help usmake surethat you gettherightsortofhelp

•You canquicklyfind out aboutthe different typesofhelp available to you

•Youwon’tbe askedforthesameinformation lotsoftimes

You can see what is on you record - Ifyou wanttocheckyourown recordortalkto someoneabouthow safe andconfidential yourpersonal information is,you should talk tothepersonwho isworkingwith you.

Data Protection: Forindependent advice aboutdata protection, privacyand data sharing issues,you cancontactthe Information Commissioner’s Office,Wycliffe House,WaterLane,Wilmslow,Cheshire SK9 5AF. Tel: 01625 545745or 08456 306060Fax:01625 524510 Website:

CVS Uttlesford Registered Charity No. 10986271