Refer Someone

Important: Integrate Hope CIC is not an emergency service. If someone is in immediate danger, call 999 before submitting this form.

1Referrer Details

Tell us about yourself so we can follow up with you about this referral.

Referral Date *

Your Full Name *

Organisation / Role *

Email Address *

Telephone Number

Your Relationship to the Person Being Referred *

2Person Being Referred

Only include information needed for safe initial contact. Do not include detailed medical, domestic abuse or trauma histories at this stage unless essential to immediate safety.

Full Name *

Date of Birth *

Pronouns (optional)

Telephone Number

Email Address

Preferred Contact Method

Phone Email WhatsApp Other

Safe Times / Days to Contact

Postcode / Area

If there are safety or confidentiality concerns about contacting this person, please note these in Section 6 (Safeguarding).

3Support Requested

Tick all that apply. You do not need to know the name of an Integrate Hope programme — we will help identify the most appropriate support.

Other support requested

4Reason for Referral

Please give a brief summary of why the referral is being made, what support would be helpful, and what the person would like to achieve. Avoid unnecessary sensitive detail.

Reason for Referral and Hoped-For Outcome *

5Communication, Accessibility & Inclusion

Preferred Language

Interpreter Required?

No Yes

Accessibility Requirements

Cultural / Faith Considerations (optional)

Other Communication Needs

6Safeguarding & Immediate Safety

Integrate Hope CIC is not an emergency service. If someone is in immediate danger or requires urgent medical assistance, contact emergency services before submitting this referral.

Safeguarding Status *

No known immediate safeguarding concern There is a safeguarding concern There may be an immediate risk to the person or someone else Unsure — please contact me

Please provide only the information needed for us to understand the concern and contact you safely

Has this concern already been reported to another service or safeguarding lead?

No Yes

Safeguarding contact: safeguarding@integratehope.com

7Consent to Referral & Contact

Please confirm the following before submitting.

The person being referred knows about this referral. The person has agreed to Integrate Hope CIC receiving this information and contacting them about support. I have explained that submitting a referral does not guarantee a place on a programme or service.

If the person has not consented, please explain why the referral still needs to be shared (e.g. a safeguarding concern)

8Child or Young Person — Parent / Carer Details

Complete this section because the person being referred is under 18 or a children’s service has been selected.

Parent / Carer Name

Relationship to Young Person

Parent / Carer Telephone

Parent / Carer Email

Is the Parent / Carer Aware of this Referral?

Yes No Not applicable / safeguarding reason

If parent / carer involvement is not appropriate because of a safeguarding or safety concern, please note this in Section 6.

9Additional Information & Declaration

Additional Information

Referrer Declaration

I confirm that, to the best of my knowledge, the information provided is accurate and relevant to this referral, and that I have shared it appropriately.

I confirm the above declaration. *

Your Name (Confirmation) *

✓

Referral Submitted

Thank you. Your referral has been received securely by Integrate Hope CIC.

Your reference number is:

A confirmation email has been sent to you. A member of our team will review the referral and be in touch with you shortly.

If you have any urgent concerns, please contact us at info@integratehope.com.

1Referrer Details

2Person Being Referred

3Support Requested

4Reason for Referral

5Communication, Accessibility & Inclusion

6Safeguarding & Immediate Safety

7Consent to Referral & Contact

8Child or Young Person — Parent / Carer Details

9Additional Information & Declaration

Referrer Declaration

Referral Submitted

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