You Can Do IT! Enquiry Complete this form to request taking part in the You Can Do IT! project. Step 1 of 3 33% LinkedInThis field is for validation purposes and should be left unchanged.Who is this enquiry for* Myself Another person About the person making the referralIf you are requesting help for someone else, please first enter your own name and contact details.Your name*Your phone number*Your Email address*Who are you?*In what capacity are you requesting help for this person.I am a neighbourI am a friendI am a relativeI am a professional workerBeds RCC Social PrescriberIs this person able to leave their home and attend a local group?* Yes No If you answered 'No' above please tell us more about why this person is limited to their home!Is this person receiving support from CMHT?* Yes No Are there any relevant risk assessments we need to be aware of?What other support have you put in place for this learner?*If your client is likely to be anxious or have other mental health challenges we will ask you to attend the first session with them.Would you be able to attend the first YCDIT session with your client?* Yes No Your organisation (if appropriate)About the personTitle*MrMrsMsDrFirst name*Surname*Address*Postcode*Contact telephone number*Is it okay to leave a phone message?* Yes No Contact email address (optional) Gender* Male Female Transgender Non-binary Unknown Prefer not to say Age range*20-2930-3940-4950-5960-6970-7980-8990+Ethnicity*White - EnglishWhite - ScottishWhite - WelshWhite - IrishWhite - Gypsy or Irish TravellerWhite - RomaWhite - Any other White backgroundMixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianMixed - Any other Mixed backgroundAsian - IndianAsian - PakistaniAsian - BangladeshiAsian - ChineseAsian - Any other Asian backgroundBlack - CaribbeanBlack - AfricanBlack - Any other Black backgroundOther ethnic group - ArabOther ethnic group - Any other ethnic groupPrefer not to sayAny needs you’d like to make us aware of?E.g. learning, language, transport or accessibility needs.Other Professionals / Organisations involved with support?Any other commentsIs there anything else you want to tell us about this referral? What help do you need?Checklist* Own a smart phone? Has broadband or Wifi at home address? Own a tablet, laptop or computer? Currently needs an interpreter to learn? Housebound (Unable to leave the house)? Would you like to find out more about our device loan service? Device make and model*Can you tell us about which devices you currently use?What do you currently use your device for?*Can you say what you use your device to do.Have you attended a YCDIT session before?* Yes No When did you come to the session?How can we help?*Where did you hear about us?*Would you like to learn how to save money on my energy bill by accessing online information and services?* Yes No Data protectionYou Can DO IT! is run by Bedfordshire Rural Communities Charity (Beds RCC) Beds RCC wants to provide you with the highest quality help and support. Everything that you tell us will be treated confidentially, but we will be keeping a record of your initial enquiry and the support we provide to you. Sometimes we may refer you to and/or contact other agencies on your behalf. They need to know that you have authorised us to refer the relevant contact details to them. These referrals will be discussed in full and agreed with you before any information is shared. In some cases, we may need to ask you for more personal information which is necessary for us to help you. This information is called ‘special category data’. This could include information about your health and wellbeing that is necessary for us to provide the services you have asked for. We will need your consent for us to keep this information. You can withdraw your consent at any time, all you need to do is contact BRCC’s Data Controller: Post to: The Data Controller, BRCC, The Old School, Cardington, Bedford, MK44 3SX Email: datacontrolled@brcc.org.uk Tel: 01234 838771 To find out more please read our privacy policy.Do you give your consent for Beds RCC to record your personal information so that you might engage with the You Can Do IT! Service?* Yes No Do you authorise Beds RCC to pass your contact details onto the relevant organisations and groups that might be able to offer you help and support?* Yes No Privacy Policy Beds RCC has a Privacy Policy which let's you know how we store and keep your data safe. Read Privacy Policy (opens in a new tab).I have read the information about the Beds RCC privacy policy shown above.* Yes
