Haringey Phoenix Group

Winkfield Centre

33 Winkfield Road

Wood Green

London N22 5RP

Tel: 0208 889 7070

Haringey Phoenix Group
Haringey Phoenix Group

Referral Form

We are always keen to hear from potential new members and would encourage anyone interested in our services, either on their own behalf or that of a relative or friend, to contact the Haringey Phoenix Group by submitting the form below.
Once the form has been received, we will get in touch by phone to clarify any outstanding questions and then, if appropriate, arrange an appointment for the applicant to attend the Haringey Phoenix Group.
The purpose of this initial meeting will be to carry out a Needs and Risk Assessment which will allow us to get to know the applicant better and for them to learn more about the charity.

We look forward to hearing from you.

Guidance: How to complete the referral form

We aim to ensure that the most appropriate support is supplied to visually impaired adults as quickly and fairly as possible. To help us to do this it is important that we have accurate information, shared with the consent of the person who needs the service. Please use the following guidance to help you to fill out the referral form correctly, and enable us to provide help to those who need it as quickly as possible.

Forms that are not completed correctly will be returned to the referrer, resulting in a delay in the service being delivered.

1. Applicant's Details
Please provide all information fully and accurately, taking extra care with the spelling of names addresses and telephone numbers.


2. Applicant Consent
A referral can only be accepted if it is clear that the applicant knows and agrees to be referred. For ''informed consent'' to be valid it needs to be ''expressed''- this means either written or verbal.
If you are the applying for support for yourself the consent box can be signed to say that you agree to your information being shared in order for the application to be processed.
If you are referring someone else and the applicant is not with you, the signature of the service user may not be possible to obtain. However, you should still obtain the consent of the applicant by reading out the statement in the applicant consent box and asking the applicant if they agree. If the applicant gives their verbal consent in this way, you should sign your name under the "referrer" box to indicate that you did secure the applicant's informed consent.
Applications cannot be processed without consent. If the applicant's consent is not indicated, the form will be returned to the referrer.

3. Referrer Details
Please complete ALL boxes fully. We will use the details you provide to contact you about the referral you have made.

4. Ethnic Origin
This question is about ethnicity, rather than nationality. Please tick ONLY ONE box.

5. Risk Issues
Please tell us about the known risks, if any, to the applicant or to others.

6. Background History/Current Needs and Other Disabilities
Please provide us with as much information as possible to help us ensure that we'll be able to meet the expectations of the applicant.