Test Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1Start2Referrer Info3Client Info4Support Needed5Demographic Options6Marketing Options7ReviewSelecting support typeChoose a Catalyst Support service and who is filling out the form.Which service would you like to refer to? *Catalyst CounsellingCommunity ConnectionsCuckooing ServiceWomen's Centre ServiceUnsureBrief descriptions of our services can be found on our website.Are you referring yourself or someone else? *SelfSomeone elseNextReferrer DetailsDetails of the person referring someone to a Catalyst Support serviceReferrer name *FirstLastReferrer email *EmailConfirm EmailReferrer organisation *Referrer phone *Please let us know about risks, safety concerns or other information about the person being referred that we should be aware of?NextClient detailsDetails for the person being referred to a Catalyst Support service.Client Name *FirstLastClient Email address *EmailConfirm EmailClient Date of Birth *Please note that we are unable to work with anyone under the age of 16Client Phone *Client Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeWhich days are best for us to contact you? *Any Week DayMondaysTuesdaysWednesdaysThursdaysFridaysWhich times are best for us to contact you?Any Time09:00 - 11:0011:00 - 13:0013:00 - 15:0015:00 - 17:00How would you prefer us to contact you ?Phone callMobile phoneText message (SMS)EmailLetterVoicemail may be leftOtherWhat method would you like for us to contact you? *NextSupport Details Please provide more information about the specific support needed, including how we may be able to help.What is important for us to know about your current circumstances? *You can share anything you feel would help us understand your situation and the support you would like to receive. Are you receiving support from other services? *YesNoWhat current support are you are receiving? * (e.g. GP, mental health team, Social worker, Probation, Housing, Domestic abuse service, Substance misuse Service, Care Coordinator)NextDemographic informationThe following questions are optional and help us ensure our services are accessible and inclusive for everyone.Sex and Gender Identity (optional)Woman (including transgender woman)Man (including transgender man)Non-binaryIntersexPrefer not to sayEthnicityAsianArabBlackMixed or multiple ethnic groupsWhiteOtherPrefer not to sayEthnicity AsianBangladeshiChineseIndianPakistaniAny other Asian BackgroundEthnicity BlackCaribbeanAfricanAny other Black background you phone the Ethnicity MixedWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed or multiple ethnic backgroundEthnicity WhiteEnglish, Welsh, Scottish, Northern Irish or BritishIrishGypsy or Irish TravellerRomaAny other White backgroundOther Ethnic Background *Sexual orientationHeterosexual/StraightGay/LesbianBisexualOtherPrefer not to sayDisability (select all that apply)No impairmentLearning disabilityPhysical disability or difficultyVisual impairmentHearing impairmentDual sensory lossNeurodiverse condition (e.g. Autism Spectrum, ADHD)Long-term illness or chronic conditionOtherPrefer not to sayList your additional DisabilitiesAre you a carer?YesNoPlease provide any information you are comfortable sharing in relation to being a carer.NextMarketing PreferencesWe'd like to understand how you connected with our service and whether you'd like to stay informed about our work. You can choose what information to share and whether you'd like to receive communications from us.How did you hear about us?Another charity or voluntary organisationCharity eventCommunity group or eventEmail or newsletterWord of mouth (Friend or family recommendation)Healthcare professional or support workerOur websitePoster or leafletSearch engine (e.g. Google, Bing)Social mediaOther (please specify)How did you hear about us? *Would you like to subscribe to our quarterly newsletter mailing list? *YesNoNextReview your information and click sendUpdating preview…Data protection statement *I have read and understood the Privacy Notice and understand how Catalyst Support will use my information.The information you provide will be collected and processed by Catalyst Support in accordance with UK data protection law, including the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018. We collect this information to help us provide appropriate services, monitor equality and diversity, understand who is accessing our services, and meet our reporting and funding requirements. Some of the information requested is considered special category data under data protection law. Where this applies, we will only collect and use the information where we have an appropriate legal basis to do so. You do not have to provide information that is marked as optional or "Prefer not to say", and choosing not to provide demographic information will not affect your access to our services. Your information will be kept securely and only shared where there is a lawful basis to do so. Further information about how Catalyst Support collects, uses and protects personal information can be found in here: Policies / Privacy - Catalyst Support PreviousSubmit
