Community help points introduction form

If you require an adult social care assessment please Email staffordshirecares@staffordshire.gov.uk or call 0300 111 8010.
For Adult Social Care practitioners only Please do not use this form but raise a CHP form on Care Director and assign the form to the Public health dashboard.
Person seeking support
Name

First name

Last name
Address

Address Line 1

Address Line 2

City

County

Postcode

Country
Date of birth
Phone
Name of person making referral

First name

Last name
Email of person making referral
Care director number (if applicable)
If you prefer a family member or carer to be contacted about the community help point offer, please provide contact details for your preferred contact.
Please provide any relevant information that you feel the help point staff should know? i.e. any communication or accessibility needs

Reason for referral
Brief details of need e.g. loneliness & isolation, mental wellbeing, help required in form filling etc. What would the person like some help with?
Is the referral to help the person to access SCC’s Entitled To benefit checker?
YesNo

Privacy notice

How we use your data
The information you provide to Staffordshire County Council (Data Controller) will be processed in line with the Data Protection Act 2018 under the legal basis of Article 6 (1) (e) for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller.
We may share your data with partners who are working on behalf of Staffordshire County Council in order to provide these services or where we are required to by law.
View our public health privacy notice
View our full privacy notice
Contact the Data Protection Officer: 01785 278314 / dpo@staffordshire.gov.uk
The following applies to any person named in this form – including family members or carers identified as contacts.
Please tick this box to confirm that it has been explained to the customer how the information will be processed and usedPlease tick this box to confirm that the customer has agreed for Community Help Point staff to make telephone contact with them

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