Referral - Aftercare Service

External Referral Form

Use this form if you want to refer a veteran or veterans' family member to the UDR & R IRISH(HS) Aftercare Service. NOTE Please complete as many of the fields as you have information for. Some fields are mandatory these are marked with an * if left incomplete the form cannot be submitted.

External Referrer Details

NOTE: No information is stored on our servers once you click on the Submit / Send button.

YOUR Name *

This is YOUR Name i.e. the individual making the referral.
YOUR Phone No *

Enter YOUR phone number so the Aftercare Service can contact you if appropriate.
YOUR email address*

Enter YOUR email address so the Aftercare Service can contact you if appropriate.
Referring Organisation *

Please select the referring organisation from the drop-down list if your organisation is not listed select "Other".
Referral (Client ) Details
Client Name * Forename Surname
Enter the forename and surname of the client you are referring.
Client Phone Number *

Enter the phone number of the client.
Client Email Address

Enter the email address of the client.
Clients Date of Birth *

Enter as DD/MM/YYY
Please enter the client date of birth in the format DD-MM-YYYY.
Client NI Number

Enter the client National Insurance Number.
Client Address *
Street Address *

Address Line 2

City *

County

Post Code *

Country *

Enter the client address.
Client Service Details
Arm in which client served *

Enter the Arm in which the client served if more than one select the Arm with the longest service.
Service Number *

Enter the client Service Number.
Client Rank

Enter the client rank on discharge.
Unit or Regiment

Enter the unit or regiment the client served in.
Service From

Enter the date of entering service (Year only) i.e. 1975.
Service To *

Enter the date of leaving / discharge from service (Year only) i.e. 2001.
Reason for client Referral

NOTE: Ensure you provide a short background as to the reason this client is being referred to the Aftercare Service and any additional relevant information.
DO NOT USE THE RETURN KEY IN THE REASON FOR REFERRAL BOX TEXT WILL AUTOMATICALLY WRAP

Reason for Referral *

Enter a brief description of why the individual is being referred to the Aftercare Service and any additional information.
Client Consent

NOTE: To comply with GDPR and Data Access legislation you need to check this consent box, in doing so you certify that you have explicit permission from the client to share their details as entered on this form, and additionally, that the client has agreed that the Aftercare Service may contact them if appropriate.

Client Consent * Client consent
By checking this box you certify that you have explicit permission from the client to share their details as entered on this form, and additionally, that the client has agreed that the Aftercare Service may contact them if appropriate.

External Referral Form

External Referrer Details

Referral (Client ) Details

Client Service Details

Reason for client Referral

Client Consent

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