Please complete our referral form below if you would like to use our service. There is a link to our privacy notice at the bottom of the page to let you know how we handle the information you provide. A lot of the questions below require an answer before you can submit the form so please make sure you have completed all sections, especially the ones with red writing. If the form won't submit it's almost definitely because you've missed a question. If you're still having problems submitting the form please give us a ring or message us, we're here to help.
All fields highlighted in red are mandatory.
There are missing mandatory fields, which are indicated by red lettering stating that it is a required field.
Please check the fields and submit the form again once completed.
We recognise that maintaining the confidentiality of certain information is necessary and are committed to practices and procedures that reflect this. We believe that information our service users give to our staff or volunteers in confidence should only be used for the purpose intended by the service user. Our staff and volunteers will not normally divulge information that could compromise a person's safety or right to privacy however there may be times when a member of staff or volunteer consider it necessary to disclose information to others within the organisation or an outside agency for the sole purpose of the safety and wellbeing and the service user and/or their family members.
Please note that information contained in this form will be stored and processed as part of our legitimate interests. Full details are contained in our privacy notice. Please ensure that the referee is aware of this.
Thank you very much for your referral.
Acacia Family Support
If you need help or support or have any questions please call.
0121 301 5990
or click here to email us