Service Referral Form

This form is for you to refer yourself, a family member, a friend or your client/patient to Age UK Lindsey's Services (this area is the district council areas of East Lindsey and West Lindsey in Lincolnshire and North Lincolnshire only).

Please check that Age UK Lindsey is the correct charity to refer to here: https://www.ageuk.org.uk/services/in-your-area/

In order for us to process a referral, Age UK Lindsey must collect personal data about you and/or your client/family member. We will therefore NOT process incorrect or out of area referrals due to GDPR guidelines.
If you are referring on behalf of someone else, please ensure that you have received their permission to do so, before submitting their data, and that you include your details in the relevant section.
If you are looking for advice about a specific topic e.g. Care & Support, Health & Wellbeing, Benefits or Winter Wellness, why not visit our online information page?

For information about how details are used and stored by Age UK Lindsey, please click here to read our privacy notice.

Who is being referred to Age UK Lindsey?

ALL REFERRALS MUST LIVE IN EAST/WEST LINDSEY (LINCOLNSHIRE) OR NORTH LINCOLNSHIRE

Please tell us more about the person being referred to Age UK Lindsey. This could be yourself, a family member, friend or your client/patient.

Title

Name

Address (ALL REFERRALS MUST LIVE IN EAST/WEST LINDSEY OR NORTH LINCOLNSHIRE)

Postcode

Telephone Number

Date of Birth

Are you...? Self-referring Referring on behalf of someone else

Reason for Referral

If you are completing this form on behalf of yourself, we now have all the personal details that we need in order to start the referral process. Please scroll down to the bottom of the page, confirm that you have read the privacy notice and then click submit. If you could also let us know how you heard about Age UK Lindsey, that will help us to reach and support more older people.

Referrer's Details

If you are completing this form on behalf of someone else (e.g. a family member, client or patient), please complete the following section. Otherwise, please scroll down to the bottom of the page, confirm that you have read the privacy notice and then click submit.

General Data Protection Laws (GDPR) dictate that consent must be obtained for a referral to be accepted and recorded. Please confirm that your client/patient/family member/friend has agreed to:

The referral being made to Age UK Lindsey Yes No

Being contacted directly by Age UK Lindsey Yes No

Age UK Lindsey storing their information Yes No

Your Title

Your Name

Your Position/Relationship to the Client

Your Telephone Number

How Did You Hear About Age UK Lindsey?

I have read the privacy notice, and agree to Age UK Lindsey collecting my data via this form