Community & Care Referral Form

Community & Care
Referral Form

As a Deaf led organisation, we have personal insight into the issues faced by D/deaf people. Our experience guides our customer centric approach and ensures that we deliver a high quality service.

New Community Booking Form 21st Feb 2023

Your Details

SERVICE USER NAME

SERVICE USER ADDRESS

SERVICE USER

SERVICE USER MOBILE/TELEPHONE

SERVICE USER EMAIL

SERVICE USER DATE OF BIRTH

SERVICE USER FIRST LANGUAGE

Social Worker

IS THERE A SOCIAL WORKER IN PLACE?

Yes

SOCIAL WORKER NAME

SOCIAL WORKER TELEPHONE

Confidentiality Policy & Data Protection Act

Action Deafness Community are committed to providing a confidential service and has a full confidentiality policy in place which is available on request.

The personal data collected on this form will only be used for the purpose of processing the referral in accordance with our policy, i.e. for administrative reasons. In addition, statistical (but not personal) information may be shared with funding bodies and the Government for monitoring purposes.

As some of the personal data we have collected is deemed sensitive under the Data Protection Act, your written consent is required. You can provide that by signing below.

AD Community members may contact you on occasions with relevant information. No details will be passed to any commercial organisation. I understand and agree to the processing of my personal data provided on this form according to the terms outlined above and confirm that all information on this form is correct.

Signed

Signed:

Please sign in the box:

Dated 18/12/2024

Theirstories

Read how our services have transformed lives.

Michael's Story

“I was new to using interpreters at work so AD made sure I had interpreters when I needed them and that I didn’t exceed my ATW budget. Having interpreters for meetings and general office discussions meant I could just get on with my work and after a few months I got a promotion.”

Bela’s Story

“I struggled to follow work meetings when my hearing deteriorated due to old age. I was shown the different types of equipment that I could use at home and at work. The equipment was excellent and I can continue to contribute to my work place with a new lease of life.”

Rose’s Story

“I felt isolated living in a hearing community. Now I have a Personal Assistant who I can sign with. My PA helps me get on with my life as normal and even helps me keep in touch with my son. My PA helped me arrange a meeting with my son, it was really emotional!”

John’s Story

“My local Deaf charity was having problems providing care services to my wife. Action Deafness stepped in to support the charity and brought a completely new way of working. The paper work improved and the managerial support for our carer really made a difference to the care my wife received.”

Pseudonyms have been used in these case studies to protect the identity of our clients

07947 714040

07528 551162