Phone 028 90 420 145

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 anĀ * 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.

  • This is YOUR Name i.e. the individual making the referral.

  • Enter YOUR phone number so the Aftercare Service can contact you if appropriate.

  • Enter YOUR email address so the Aftercare Service can contact you if appropriate.

  • Please select the referring organisation from the drop-down list if your organisation is not listed select "Other".

  • Referral (Client ) Details

  • Enter the forename and surname of the client you are referring.

  • Enter the phone number of the client.

  • Enter the email address of the client.

  • Please enter the client date of birth in the format DD-MM-YYYY.

  • Enter the client National Insurance Number.

  • Enter the client address.

  • Client Service Details

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

  • Enter the client Service Number.

  • Enter the client rank on discharge.

  • Enter the unit or regiment the client served in.

  • Enter the date of entering service (Year only) i.e. 1975.

  • 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.

    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.

    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.

Need Help?

Contact us for practical help, welfare advice or medical services

Regional Field Teams

North (Coleraine Area)

028 92 260 615

South (Portadown Area)

028 92 260 044

East (Holywood Area)

028 90 420 266

West (Enniskillen Area)

028 92 260 114
"Helping our people in need to live their lives"