Customer Referral Form

Please complete the referral form with as much detail as possible and attach documentation that is requested in the form. Missing information may delay or prevent Appointee Services being able to accept the referral and start the referral process.
If the customer has the mental capacity to authorise referral, the referral can only be accepted on receipt of a signed letter of Authority
The referral can only be accepted on receipt of a capacity test if the customer lacks the mental capacity to authorise the referral.
Please provide the signed letter of relinquishment if the customer has an existing Appointee or Power of Attorney who is agreement with the referral,
If the customer has an existing Appointee or Power of Attorney who is not in agreement with the referral, please provide a supporting letter which may be forwarded to the DWP/OPG outlining why it is the customer’s best interest for Appointee Services to intervene against the existing representative’s wishes

The start-up process:

A referral form received by health professional, social worker, customer or other – if the form is completed in form then Appointee Services will complete the following:

Appointee Services Ltd will allocate a team member for each customer
Appointee Services Ltd will open bank account (4 working days)
BF56 from (provided by DWP) completed by Appointee Services Ltd (1 day)
Appointee Services Ltd will agree and set up with the customer or care manager a budget plan
Appointee Services Ltd will receive notification of Appointeeship by the DWP (dictate by DWP, can take up to 8 weeks)
Appointee Services Ltd will act in accordance with the budget plan (48 hours) once monies are received into the appointee bank account

Referrer Details

Name *

First

Last

Team *

Email *

Phone *

Date Referred *

Customer Details

Name *

First

Last

Date of Birth *

Marital / Civil Partnership Status *

Title *

Nationality *

National Insurance No *

Permanent Address *

Address Line 1

Address Line 2

City

County

Post Code

(home address if customer is temporarily in care or recently moved to permanent care)

Does the customer live at their permanent address?

If no you will be asked to provide their current address

Current Address

Address Line 1

Address Line 2

City

County

Post Code

(if customer is not residing at permanent address)

Does the customer live with a partner as part of a couple? *

Does the customer have a financial interest in a property *

Is the customer in receipt of Direct Payments? *

Additional Communication Needs *

Reasons for Referral

Please explain why the customer cannot manage their own financial affairs and give an overview of the customer’s illness/disability. *

Are you able to attach a copy of the customers last care needs assessment or review? *

Yes
No

Has the referral been prompted by Safe Guarding concerns? *

Customer Capacity

Does the customer have the mental capacity to understand and consent to the referral being made?

Yes
No

Attached a letter addressed to DWP and/or Pension Service explaining the reasons why an appointee is required *

Click or drag a file to this area to upload.

GP Details

Name of GP

Practice Name

Practice Address

Address Line 1

Address Line 2

City

County

Post Code

Practice Phone

Practice Email

Care Provision

Name of Service Provider

Is care funded? *

Full funded
Care Contribution

Contact details

Existing Financial Representative Details

Is the existing financial representative?

Yes
No

Address *

Address Line 1

Address Line 2

City

County

Post Code

Next of Kin

Do you need to provide details of the customers next of kin? *

Yes
No

Address

Address Line 1

Address Line 2

City

County

Post Code

Significant People

Do you need to provide details of Significant People? *

Yes
No

Address

Address Line 1

Address Line 2

City

County

Post Code

Life Planning

Has the customer made a will?

Does the customer have an existing funeral plan?

Capital and Savings

Please provide details of all bank, building society or other accounts held by the customer or by a third party on their behalf including current accounts, savings accounts, bonds, ISA's, stocks and shares or other investments.

Capital and Savings

Name of Institution *

Sort Code *

Account number *

Balance *

Please attach documents related to the above income

Click or drag files to this area to upload. You can upload up to 5 files.

Income

Please provide details of all of the customer’s incomes including benefits, income from private pensions or annuities, earnings, and any income from trust funds.

Income

Income Type

Reference or Policy No

Amount

Payment Frequency

Debts

Please provide details of any debts the customer has.

Debts

Debt owed to

Balance Owed

Reference

Existing Payment Arrangement

Please Attach details of Debts

Click or drag files to this area to upload. You can upload up to 5 files.

Landlord Details

Does the Customer have a Landlord? *

Yes
No

Landlord Address

Address Line 1

Address Line 2

City

County

Post Code

Utilities

File Upload

Click or drag a file to this area to upload.

If you have been unable to provide all the necessary information, please provide details of the person who may be able to help provide the information needed otherwise we will be unable to progress your referral

Name

First

Last

Relationship

Phone

Email

Please use this section for any additional information not referenced elsewhere on the form that may be needed to progress the referral.

Paragraph Text

Services Required – Please Indicate

Services Required?

Additional Services

Allpay Card £30.00 set up fee and £7.00 per month
Protection of Property £85.00 initial and £35.00 per month

Multiple Items

First Item
Second Item
Third Item