COMMUNITY CONNECTORS
PROFESSIONAL REFERRAL

Referrer's Details

Name of Agency *

First Name

Last Name *

Email Address

Phone

Client's Details

First Name

Last Name *

Email Address

Phone

Street Address

City

ZIP / Postal Code

Preferred contact method

Preferred time of day to contact

Additional Client Details

Are there any additional needs or vulnerabilities which we should be aware of, in order to provide appropriate support and make reasonable adjustments where possible? (e.g. physical or learning disability, neurodiversity, long term medical conditions, mental health support needs )

If yes, please provide details

Does the client have any dependant children?

Is the client a named Carer?

Any other relevant information

Key issues identified where client may need additional support / signpostingChildren / Families / RelationshipsConfidenceDomestic AbuseEducation & TrainingEmploymentFinance / Debt / BenefitsHousingMotivationSocial IsolationSocial SkillsVolunteeringNone of the above

Reason for referral to Community Connectors

What is the nature of your agency's involvement?

Will you be continuing to work with the client?

Are there any other agencies involved? If so, please provide name and contact details and nature of involvement

Are there any risk factors that the team need to know before the service user comes to groups?*

If yes, please provide details

* If you consider a risk assessment is needed for the service user’s, peer’s or staff’s safety, please send to connectors@worcestercommunitytrust.org.uk. This information will be stored in line with GDPR and our data protection policy.

Would you be interested in receiving a WCT newsletter?

Worcester Community Trust is a registered charity 1112342
Registered Company Number 04722577

Registered Office:
The Green Centre,
Gresham Road, Dines Green,
Worcester, WR2 5QS

Annual Report
Privacy Policy
Safeguarding Everyone Policy

COMMUNITY CONNECTORSPROFESSIONAL REFERRAL

Referrer's Details

Client's Details

Additional Client Details

COMMUNITY CONNECTORS
PROFESSIONAL REFERRAL