Lamp Referral Form

PLEASE NOTE THAT WE ARE UNABLE TO ADVOCATE FOR SOMEONE WITHOUT THEIR AGREEMENT AND PERMISSION. ONCE YOU PROVIDE THEIR DETAILS, WE WILL ATTEMPT TO MAKE CONTACT WITH THEM TO GET THIS AGREEMENT. IF THEY ARE UNABLE OR UNWILLING TO GIVE THEIR AGREEMENT, WE WILL BE UNABLE TO SUPPORT THEM. 

Self Referral or Third Party

• SELF-REFERRAL
• THIRD PARTY REFERRAL

PLEASE NOTE THAT WE ARE UNABLE TO ADVOCATE FOR SOMEONE WITHOUT THEIR AGREEMENT AND PERMISSION. ONCE YOU PROVIDE THEIR DETAILS, WE WILL ATTEMPT TO MAKE CONTACT WITH THEM TO GET THIS AGREEMENT. IF THEY ARE UNABLE OR UNWILLING TO GIVE THEIR AGREEMENT, WE WILL BE UNABLE TO SUPPORT THEM.

Personal Details

Name *

First

Last

Email *

Preferred method of contact *EmailPhone

Phone *

Date of Birth *

Ethnicity *Asian or Asian BritishBlack, Black British, Caribbean or AfricanMixed or multiple ethnic groupsWhiteOther ethnic group

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Gender *MaleFemaleNon-BinaryTransgenderGender NeutralDo not wish to state

How did you hear about Lamp? *

How would you like us to help? *I need help getting the medical treatment I needI need help understanding my rightsI need help to be listened to by my doctorsI need help at an appointmentI need help reaching services which can support meI need help with something else

Please tell us in more detail why you need our help *

In a few words, please explain what issues you are facing and what you would like to achieve with an advocate

Supporting Documents

Click or drag files to this area to upload. You can upload up to 10 files.

Anything you deem helpful in is supporting you. Eg. Doctors Letter, Appointment Dates

Custom Captcha *

=

Submit