This referral form is for self-funding referrals for Assistive Technology only.

REFERRER DETAILS

CUSTOMER DETAILS

Customers contact number, not a relatives etc

DETAILS OF SERVICE REQUIRED

DETAILS FOR BOOKING THE APPOINTMENT

PAYMENT DETAILS

All Customer have to pay a mandatory upfront cost for the set up of the equipment. This will be discussed with you at booking stage.

GDPR

GDPR Statement - The information you provide will be used to assist us in understanding your enquiry. We may also use it to communicate with you and provide the services you need or are entitled to receive and to monitor our performance in providing services to you; to gather statistical information to allow us to plan future provision of services and to obtain your opinion about our services. We may share data with other council services & partner organisations to ensure records are kept accurate and to identify services or benefits you may be entitled to or interested in. It is therefore very important that you notify us if any of the information you have provided changes at any time. We may also need to share your information for the prevention and detection of fraud and/or other crimes or as the law requires. If you would like to learn more about how Solihull Community Housing uses personal data please refer to our Privacy Notice on the website.