Third Party Referral

A professional, friend or family member can make a referral for someone who needs our help. This is called a Third Party Referral and can be completed below.

Please make sure that the person who needs our help meets the following criteria

• Lives in Peterborough
• Is aged 18 years old or above
• Has a Learning Disability and/or Autism

Referrers Name (The person completing this form) *

First

Last

Referrers connection to the client: *

E.g. Social Worker, Health Visitor, GP, Nurse, Friend

Your Email *

Your Telephone Number *

Do you have the permission from the person that needs help to make this referral and share their details? *

• Yes

We can only take referrals from third parties if you have permission from the person you are referring.

The persons name whos needs our help? *

First

Last

How old is the person who needs our help? *

We can only help people who are aged 18 years old or above

Does the person who needs our help have a Learning Disability and/or Autism *

• Yes - Learning Disability
• Yes - Autism
• Yes - Learning Disability and Autism
• No - They have neither,

We can only help people who have a Learning Disability and/or Autism.

The address of the person who needs our help: *

This must be a Peterborough address, we can only help people who live in Peterborough.

The Telephone number of the person who needs our help *

Email address of the person who needs our help

Please leave blank if they do not have one.

What do they need help with? *

Any other details you think we need to know?

Helpful information could be: Do they have a statement, EHCP or care package? Do they have evidence of a diagnosis? Any benefits they may be getting? Any thing else:

Submit