We’re here to help! : Umbrella Cymru

I am requesting support for:*

Type of Support*

What will the support relate to?*

Is your organisation a Corporate Member?

Yes
No
I don't know

Have you requested support for someone before?

Yes
No

Have you contacted us before?

Yes
No

Consent to request support?*

Do you have consent from the person to request support or services on their behalf?

Yes
No

Please contact us

If you are trying to request support for someone who is not aware of the request or referral but you believe they are at risk, please contact us to discuss this information and we will be able to advise you of the best course of action to take in this instance. Alternatively, you can complete the information below and we will contact you as soon as possible.

Client Information

This must be the information for the person the request is for or about.

Name (known as or preferred)*

First Last / Family Name

Pronoun Group

Preferred Language

Language - Other

DOB*

Gender*

Other Gender Identity

Sexual or Romantic Identity

Other Sexual or Romantic Identity

Client Contact Details

Address

Address Line 1 Address Line 2 Address Line 3 Address Line 4 Postcode

Method of Contact

IMPORTANT!! Please provide us with as much information as possible. The more details we have, the more likely we'll be able to contact. Please TICK AS MANY AS POSSIBLE!

PLEASE NOTE: We regularly use emails to contact people in the first instance. Sometimes, our emails can get filtered by certain email accounts such as hotmail. Please CHECK your junk folders periodically for emails from us just in case to prevent any delay in contacting you.

Please contact the person you are referring to request their email address if possible. To help us bring down waiting times, we like to use email to contact clients. We also use an online booking system for appointments which can be emailed to the client. It is not impossible to contact without an email address, but we find it to be on e of the most effective methods of communication.

It's OK to:*

Tick as many as possible.

Email
Call Mobile
Text Messag (SMS)
Leave Voicemail on Mobile
Call Home
Leave Voicemail on Home Phone
Letter Home
Contact Via Referrer
Contact Via Parent / Carer / Guardian

Email

If you are requesting support for yourself, you will receive confirmation to this email address. If you are requesting support for this person, the notification will be sent to the email address you provide further down the form instead.

Enter Email Confirm Email

Mobile Number

Home Telephone

Parent, Carer, Guardian Details

Please provide details including NAMES and contact information. It is IMPORTANT that any contact details for the person being referred are for them (not anyone else's). Any additional contact information for parents / carers / guardians should be included HERE INSTEAD.

Parent, Carer, Guardian Name

First Name Last / Family Name

Parent, Carer, Guardian Pronoun Group

Parent, Carer, Guardian Preferred Language*

Safe to:

Tick as many as possible.

Email
Call Mobile
Text Messag (SMS)
Leave Voicemail on Mobile
Call Home
Leave Voicemail on Home Phone
Letter Home

Email

If this is your email address and you are the parent, carer or guardian mentioned here, you will receive a confirmation email. If you are not the person named here, we will send confirmation to your email address instead.

Enter Email Confirm Email

Mobile

Home Number

Address (if different)

Address Line 1 Address Line 2 Address Line 3 Address Line 4 Postcode

Additional Details

Is there anything we need to know about making contact through a parent, carer or guardian?

Any specific contact requirements?

This could include a specific time or day to contact, or specific language or access requirements.

Your Information

Have you already provided your details above?

Yes - I am the parent, carer or guardian named above
No

Agency / Organisation Name

Agency Reference?

If you have a specific case number or other reference number, you might wish to include it here.

Hidden

Full Name (person making this request)

Your Name

First Last / Family Name

Your Pronoun Group

Your Preferred Language

Your Preferred Language - Other

Your Email

You will receive a confirmation email to this address with details of our process and any current waiting times.

Enter Email Confirm Email

Best contact number

Your Department

Your Job Title / Role

Your Office Telephone Number

Nature of Request / Support

Does this request relate to an incident of crime?

Yes
No
Unknown

Crime Information

Involvement in Crime

Has this been reported to the Police?

Yes
No
Unknown

How was the incident reported to the Police?

Crime reference number (if known)

Date of incident / Date reported

Force Area

Crime Type / Category

Was this a hate incident?

Victim Support Reference?

Details

Request for:*

Other Support

IMPORTANT!! Please use this section to provide us with information about the request for support including what you or the person you're requesting support for would want from our service. This should include as much information as possible. Please include dates and details of any support received to date. The more information you can provide, the better we will understand how to help.

Details about the request*

Non-Consent to Refer Details

You have indicated above that you are attempting to make a referral without explicit consent. Please do NOT provide details that should not be shared in this section, but please DO tell us how and when would be best to contact you to discuss this matter.

Risk

Risk to Self

Risk to Others

Vulnerability

Consent

To read our full confidentiality and information sharing policy, please visit www.umbrellacymru.co.uk/confidentiality

Consent to Store Information

The information you have provided in this from will be sent to Umbrella Cymru to be processed. Your information will be kept on a secure database. Our team has access to this information to provide you with the best support we can. Your information is kept confidential and we will only breach this confidentiality if we are aware that a you or another person is at risk of harm to themselves or others. Do you consent for your information to be stored in this way and for this purpose?

Yes

Consent to Share Information about the crime?

You have indicated that this referral relates to a crime or antisocial behaviour, do you consent for us to share your information with Victim Support and the relevant Police Force to determine if any additional support is available? If you agree to this, Victim Support and the relevant Police Force might contact you to discuss this.

No - Do not share information with Victim Support or the Police
Yes - Share with Victim Support AND the Police
Yes - Share with Victim Support ONLY
Yes - Share with the Police ONLY

Consent notes

Please make any specific notes in relation to consent to share information below: