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 Service and who is filling out the form.Which service would you like to refer to *Catalyst CounsellingCommunity ConnectionsCuckooing ServiceWomen's Centre ServiceBrief descriptions of our services can be found on our website.Are you referring yourself or someone else? *SelfSomeone elseNextReferrer DetailsDetails of the person refereeing someone to a Catalyst service.Referrer name *FirstLastReferrer email *EmailConfirm EmailReferrer organisation *Referrer phone *NextClient detailsDetails for the person being referred to a Catalyst service.Client Name *FirstLastClient Email address *EmailConfirm EmailClient Date of Birth *Client Phone *Client Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeNextSupport DetailsGive us more information about what specific support is required so we can support you.What areas would you like support with *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 informationSex and Gender Identity (optional)Woman (including transgender woman)Man (including transgender man)Non-binaryIntersexPrefer not to sayEthnicityAsianBlackMixed or multiple ethnic groupsWhiteOtherPrefer not to sayEthnicity AsianBangladeshiChineseIndianPakistaniAny other Asian BackgroundEthnicity BlackCaribbeanAfricanAny other Black backgroundEthnicity 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)Mental healthLong-term illness or chronic conditionOtherPrefer not to sayList your additional DisabilitiesAre you a carer?YesNoNextMarketing PreferencesSo we can help you and more people like you.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? *How 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? *Which days are best for us to contact you?Any DayMondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundaysWhich times are best for us to contact you?Any Time0800 - 11:0011:00 - 14:0014:00 - 17:0017:00 - 20:00NextReview your information and click sendUpdating preview…Data protection statement *I understandThe 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 you support are PreviousSubmit
