Referral form: Adults

Thank you for contacting Sensory Services by Sight for Surrey. This form helps us understand how we can support you (or the person you are referring).

Before you start

You can use this form to:

To request support for yourself (self-referral), or
To refer someone else (with their permission)

Your information and consent

We will keep your information safe and confidential. We only use it to understand your needs and provide the right support.

For more details, please read Sensory Services by Sight for Surrey Privacy Notice.

Please tick this box if you agree to us holding your personal information and data

Yes, I agree No, I don't agree

If you are completing this for someone else, please make sure they know and agree to us holding their personal information and data

Yes, they agree No, they don't agree Not applicable

Is the person being referred aware of and providing consent for this referral?

Yes, they are aware and consent No, they are not aware and/or consenting Not applicable

If the person cannot give consent, are you acting in their best interests?

Yes, I am acting in their best interests No, I am not acting in their best interests Not applicable

Date of referral

Person being referred

This could be yourself or someone else.

Name

Date of birth

House name or number

Street name

Post code

City

County

Contact phone number

Contact email

Are you/person being referred registered with a Surrey GP?

Yes No

Details of person referring

If you are self-referring, ignore this section.

Name

Relationship to the person

Name of organisation (if applicable)

Contact phone number

Communication needs

Do you have any communication or language needs? For example: British Sign Language (BSL), lip reading, easy read, foreign language etc)?

Yes No

If you answered yes, please tell us more

About you

Do you have an eye condition?

Yes No

If you answered yes, please tick any that apply

If you ticked other, please tell us more

Do you have any difficulty with your hearing?

Do you use any hearing devices? Please tick any that apply

Hearing aids Cochlear implant Bone Anchored Hearing Aid (BAHA) None

Do you have a combined sight and hearing need?

Yes No

What would you like support or advice with?

If you have ticked Telephone / SMS, please ensure you have provided a relevant contact above. If you have ticked Email, please ensure you have provided a relevant contact above.

If you ticked contact through a family member, friend, or carer, please provide details

Have you used our service before?

Yes No

If you answered no, how did you hear about us?

Optional: About you

These questions are optional and help us improve our services. Your answers will not affect your referral.

Would you like to answer these questions?

Yes No

If you answered no, please ignore the questions below.

Do you consider yourself disabled?

Yes No Not sure

What is your gender?

Male Female Other Prefer not to say

You will receive notification your referral has been submitted.

A member of our team will aim to contact you within 2 working days. If we are busy, it may take a little longer. We will be in touch as soon as we can.