Welfare Benefit referral form – WordPress on Azure

Please use this form to make a referral to the Welfare Benefits service. Please provide as much information as possible as the team are unable to assist you/residents without a valid referral.

Please call 020 8708 4180 or email if you have any queries.

Referrer Source(Required)

Self-referral

Friend/Relative/Carer/Appointee

LBR internal

External Organisation

Warning Before completing this form, you must have the resident’s permission to do so.

Consent(Required)

Please confirm you have permission to refer the resident and share their personal data

Self referral

Your details

Friend/Relative/Carer/Appointee

Your details

LBR staff (internal) referral

Your details

External organisation referral

Your details

First name(Required)

Last name(Required)

Date of birth(Required)

National Insurance number(Required)

Your relationship to resident (person you are referring)(Required)

LBR internal

About the external organisation

Organisation name(Required)

Job title(Required)

Department(Required)

Location(Required)

Self referral

Your contact details

Friend/Relative/Carer/Appointee

Your contact details

LBR staff (internal) referral

Your contact details

External organisation referral

Your contact details

How would you like us to contact you?(Required)

Telephone

Email

Telephone(Required)

Email(Required)

Telephone

Email

Address (Enter Postcode)(Required)

Find address

About the person you are referring to our service

First name(Required)

Last name

Date of birth(Required)

National Insurance number

Contact details for person you are referring

How would they like us to contact them?(Required)

Telephone

Email

Telephone(Required)

Email(Required)

Telephone

Email

Address (Enter Postcode)(Required)

Find address

About your UK residency

About their UK residency

Are you a British Citizen

Yes

No

Are they a British Citizen

Yes

No

Do you have the Right to reside in the UK

Do they have the Right to reside in the UK

About other people that live with you

About other people that live with them

Do you live on your own?(Required)

Yes

No

Do they live on their own?(Required)

Yes

No

Do you have a partner(Required)

Do they have a partner(Required)

How many children under 18 years live with you?

How many children under 18 years live with them?

How many other adults live with you?

How many other adults live with them?

Please provide your partner’s details

Please provide their partner’s details

First name(Required)

Last name(Required)

Date of birth(Required)

National Insurance number

Details of assistance required

Please state exactly what assistance you would like the Welfare Benefits Team to provide(Required)

Please state exactly what assistance they would like the Welfare Benefits Team to provide(Required)

Other details

Please use this space to tell us anything else you think we need to know

File upload (jpg, gif, png, pdf)

You may upload any supporting documents/ evidence you have that may help the Welfare Benefits Team to support you, such as,
• letters from clinicians (GP, consultant etc) that confirm your diagnosis/medical condition(s)
• social worker reports
• care plans
• notification letters from Department for Work and Pensions (DWP) or Pension Service (PS) about your Benefits

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Declaration(Required)

I agree that the information provided is correct and to the best of my knowledge.