Allotment GSP- Referral Form

Data Collection Notice

As the person making this referral your contact details will be added to our database. Access to the database is restricted to Manchester Mind staff.

Under GDPR we hold and use this data on the basis of Legitimate Interest. To enable us to deliver our service to the person you have referred.

Your details will be used by our staff to contact you in case there is a further issue with the referral. (If we are unable to contact the person you have referred, or if we need further information).

We will not use this data for any other purpose. And will not share your details with any other organisation.

All information provided will be held securely by Manchester Mind in accordance with our Privacy Statement.

This form is intended for you to refer another person to our Welcome and Access services.

If you want to access Welcome and Access services yourself, please complete our Enquiry Form instead.

Your Details

First Name

Last Name

Phone Number

Please give us either an email address or a phone number in case we need to contact you regarding this referral

How did you hear about us?

Another Manchester Mind service

Family or friend

Other

Other Organisation

Previously used our services

Saw a presentation

Search engine

Social Media

Please describe how you heard about Manchester Mind- if not listed.

About this referral

What is your connection to the person you are referring?

Referring Organisation

Organisation Name

Address Line 1

Address Line 2

Address Line 3

Town/ City

Postal Code

Phone Number

Is this person aware that a referral is being made on their behalf, and that their details are being shared with Manchester Mind?

Yes

Please make sure the Young Person is aware Manchester Mind will be in contact with then before continuing with this referral.

Person being referred

First Name

Last Name

Address Line 1

Address Line 2

Address Line 3

Town/ City

Postal Code

Please leave at least one phone number for this person, so that our staff can contact them about the Food For All service.

Mobile

Phone

Please confirm the Manchester City Council ward they live in. *

Not sure of your local council ward? Find out using this postcode search.

Personal Details

The demographic details below help us to track the communities who accesses our services. If you do not know the answer to any question, please leave it unanswered.

Birth Date

How do they describe their gender?

Female

Male

Non-binary

Another/ prefer to self-describe

Prefer not to say

Gender (other)

Have they ever identified as trans?

Yes

Prefer not to say

What is their ethnic background

Ethnic background (other)

Current Living Arrangments

Living Arrangements (Other)