Change Up Digital Referral (Prison)

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Document ID

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Referral Date

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Email Referral Inbox

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Referrer's full name* This field is required.

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Referrer's Email* This field is required.

example@example.com

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Referrer's Job Title/Department?* This field is required.

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Does your client consent to being referred to The Forward Trust Change Up Programme?* This field is required.

Yes

No

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Please ensure that your client is aware of the referral you are making to the Change Up Programme and that a Programme Facilitator will be in touch shortly. Thank you!

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Clients full name* This field is required.

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Clients prison number* This field is required.

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Client date of birth* This field is required.

Date

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Why is the client being referred to the programme?* This field is required.

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What substance(s) is/was the client using ?* This field is required.

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Does the client want to cut down or stop using substances?* This field is required.

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What progress would the client like to achieve?* This field is required.

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If the client is using different substances, which one worries them the most?

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Consent Introduction

This digital form is a summary of how your personal information will be used. We at Forward ask you for information about yourself in order to provide you with our service to match your needs and continuity of care.

We only keep your information with details of your participation for a period as long as necessary to fulfil the purposes we collected it for.

You have the right to apply for access, correction, erasure, transfer, object to processing or restrict the information we have recorded about you. You have the right to withdraw your consent at any time.

Any information we keep about you is kept confidentially within the service and stored securely except when we have a duty to share information or if you give us permission to share information.

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Duty To Share Information

We have a duty to share information with or without your permission under certain circumstances. Wherever possible, we will discuss this with you first. We have a duty to share information:

If the safety/security of other service users, staff or the community is compromised by not revealing information.

If your Forward team believes you may be at risk of self-harm or risk of harm to any person.

If your Forward team has concerns for the welfare of any child(ren).

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Where We Store Your Information

We store your information within secure case management system. Our systems store information in the UK and the EU only. For more information please see www.forwardtrust.org.uk. We may also store your information on our cloud based Microsoft Office 365 system, documents are held on Microsoft SharePoint and the data centres are based in the UK.

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Complaints

We are committed to protecting your personal data but if for some reason you are not happy with any aspect of how we collect and use your data, you have the right to complain to the Information Commissioner’s Office (ICO), the UK supervisory authority for data protection issues (www.ico.org.uk).

We should be grateful if you would contact us first if you do have a complaint so that we can try to resolve it for you.

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Contact Information

If you wish to find out more about how your information is used, please speak to your Forward worker or visit the privacy policy on our website at www.forwardtrust.org.uk.
or write to us at:

The Forward Trust
Edinburgh House Unit 106-7
170 Kennington Lane
London
SE11 5DP

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I have read and understand the conditions of this referral form* This field is required.

Client signature

Signature on behalf of client

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Signature* This field is required.I have read and understand the conditions of this referral form

Clear