Macmillan referral form If you would like to make a self-referral or if you are professional and would like to refer someone to our service then please complete the form below. For self-referrals we will contact you within 3 working days. If you have made a professional referral we will contact the patient directly within 3 working days. Please Confirm you have permission to refer your client to Citizens Advice Milton Keynes * By ticking this box you are confirming you have permission to pass on the personal details of your client and that you have obtained your client’s explicit consent to share their Special Category Data with us, as per the requirements of the General Data Protection Regulation (GDPR) 2018, where this applies. Is this a professional or self referral? * Professional Referral Self-Referral Your Email Address * Your Name Your Position/Role Your Telephone Number * *Please provide some contact details or telephone number in the event that we are unable to contact your client. Subject of Referral Clients Name * Client's Telephone Number * Can we leave a message on this number? Yes No Clients Email Address (if known and client is happy to be contacted in this way) * Address Address Address Address City City County County Postcode Postcode Which hospital are you receiving treatment at? * Milton Keynes University Hospital Stoke Mandeville Hospital Which hospital is the client receiving treatment at? * Milton Keynes University Hospital Stoke Mandeville Hospital Which of the following best describes the main issue/s involving the person you are referring to us - please select as appropriate : * Benefits Debt and Money Housing Family and Relationships Employment - problems at work Employability and Skills - looking for work Immigration Consumer Energy and Utilities Legal Discrimination Health and Social Care Education Tax OtherOther Which of the following best describes your issue- please select as appropriate: * Benefits Debt and Money Housing Family and Relationships Employment - problems at work Employability and Skills - looking for work Immigration Consumer Energy and Utilities Legal Discrimination Health and Social Care Education Tax OtherOther Please summarise what help the client requires * 0 of 150 max words Please summarise what you require * 0 of 150 max words Remember to include any urgent deadlines, times that the client might be unavailable for us to call back and any other relevant information. If you are human, leave this field blank.