CB Plus

Secondary menu

CiviCRM

Self referral form- COVID-19

Submitted by sarah@gmcvodata... on Mon, 06/04/2020 - 11:09

How your information will be used

CommUNITY Barnet will collect and use the information you give us to undertake our functions as a COVID- 19 Helpline to deliver services to you. It is our responsibility to ensure that your information is kept safe. Where necessary and legally allowed, we will share your information with trusted external organisations, commissioned partners and contracted service providers in order to deliver services and support to you.

For further details of how we use your information and to understand your rights please visit https://www.communitybarnet.org.uk/privacy-policy

I have read and understood the statement above *

Yes

Your details

First Name *

Last Name *

Street Address *

Street Address Line 2

Street Address Line 3

City *

Postal Code *

Phone Number

Email *

Information

Type of help needed *

Prescription

Shopping, essentials

Shopping, misc

Social phone call

Other

Please give more details of help needed *

How soon assistance is needed *

Within 24 hours

Within 5 days

Not now, but soon

Other

Please give more details of when assistance will be needed *

Do you have a disability, or medical condition we need o be aware of? *

Yes

If yes,how does it effect you and is there anything we should be aware of? *

Are you able to pick up shopping/medication from your front door? *

Yes

Secondary menu

You are here

Self referral form- COVID-19