Referrer Letter Form
Please complete the following form and submit

I am making this referral in the best interests of the applicant and the personal information I am providing about the applicant is accurate to my knowledge. I have explained to the applicant that, in making this referral, I am sharing their personal data, including health information, and the applicant has agreed to this. I have explained that Independence at Home will be using the information to assess their grant application.
I confirm I have explained the application process and have the permission of the applicant to share all the information included within this grant application. (Please note that we are unable to consider grant applications where you do not have permission to share such information.)

Hide Section - Grant Application on behalf of

Grant Application on behalf of

  
  
  
  
  
  
  
Hide Section - Part 1 Referrer Contact Details

Part 1 Referrer Contact Details

  
  
  
Hide Section - Part 2 (A) Referrer Information

Part 2 (A) Referrer Information

  
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Hide Section - Part 2 (B) Medical Confirmation to back up Referral

Part 2 (B) Medical Confirmation to back up Referral

If the referrer is not a qualified health professional we need to have medical confirmation of the applicant’s diagnosis
Please attach a copy letter or report from a qualified health professional in support of your application confirming the applicant’s medical diagnosis. This must have been provided within the last twelve months and be written on their letterhead paper
Hide Section - Payee Details

Payee Details

Please note that GRANTS CAN ONLY BE MADE PAYABLE TO THE SUPPLIER OR THE REFERRING ORGANISATION and NOT TO THE CLIENT  
  
For BACS payments we need bank account details of the supplier or referring organisation  
  
Please ensure you have all your supporting documents available to upload before pressing the 'submit button'