Macmillan referral form - Citizens Advice Milton Keynes

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Home > Macmillan referral form

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.
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