If you would like to refer a client into our services, please complete the following form.

Inter-agency referral form * = Required
Please confirm that the client is aware of and has agreed to this referral *	Client is aware of and has agreed to this referral Client is NOT aware of and has NOT agreed to this referral
If the client is NOT aware of and has NOT agreed to this referral, please obtain client consent before continuing *	Client consent confirmed
Your first name *
Your last name *
Your telephone number
Your email address
Who do you work for? *	Please Select Blackpool CCG Blackpool Council DWP Other Voluntary organisation
Please state name of other/voluntary organisation
Which service(s) do you want to refer your client to? *	Benefit appeals Covid response project Debt ESA50 form completion PIP form completion UC50 form completion
Client's first name *
Client's last name *
Client's address *
Client's telephone number
Client's email address
Client's preferred methods of contact *	Email Letter Telephone
Client's best days/times of contact *
Please briefly describe the primary issue you would like us to look at *
Which GP surgery is the client registered at?
Please let us know of any additional information to help us to allocate the right help for the client	Digital help needed Language barrier Literacy barrier Physical or mental health issues
Additional information - please use this box to provide us with any other relevant information regarding this client
Is the client in dispute with another individual? *	Please Select No Yes
If yes, please provide further information
Has the client presented with any behaviour that is contrary to the wellbeing of staff? *	Please Select No Yes
If yes, please provide further information
Please confirm that you agree to Citizens Advice Blackpool storing the information you have provided in acceptance with their privacy policy. *	Please Select I agree I disagree
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