Safe and Sound Contact Centre Referral - Solihull Community Housing

This referral form is for self-funding referrals for Assistive Technology only.

Contact Centre advisor name *

First

Last

How did you hear about us? Please select: *

What is the promotional offer? *

Please provide referral code *

For refer a friend please provide the name of the customer that is currently on the safe and sound service For SCH tenant please confirm that you have checked the rent account and the customer is not in arrears.

Please select the agency *

Please provide the Agency name *

Please provide more details *

REFERRER DETAILS

Referrer name *

First

Last

Referrer Email *

CUSTOMER DETAILS

Customer Name *

First

Last

Customer Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

What is the customers tenure type?

Customer email (required for self install)

Email

Confirm Email

Customer Phone *

Customers contact number, not a relatives etc

Customer Date of Birth *

DETAILS OF SERVICE REQUIRED

What service level is required *

What equipment is required? (more than 1 can be selected but any item selected other than pendant only will require assisted installation so will need to pay £104.76 ) *

DETAILS FOR BOOKING THE APPOINTMENT

Do we need to contact anyone else to book the appointment? *

Representative's name *

First

Last

Representatives phone

Representatives relation

All Customer have to pay a mandatory upfront cost for the set up of the equipment.

PAYMENT DETAILS

Were the upfront costs taken? *

What costs were taken? Advisor please select the relevent option here *

Customer Email *

Email

Confirm Email

Amount taken *

Receipt number *

Do we need to contact anyone else to take the upfront costs? *

Representative Name *

First

Last

Representative Phone *

Representative relation *

GDPR

Would you like a copy of this email sent to you for your own records? *

Yes
No

GDPR Statement - The information you provide will be used to assist us in understanding your enquiry. We may also use it to communicate with you and provide the services you need or are entitled to receive and to monitor our performance in providing services to you; to gather statistical information to allow us to plan future provision of services and to obtain your opinion about our services. We may share data with other council services & partner organisations to ensure records are kept accurate and to identify services or benefits you may be entitled to or interested in. It is therefore very important that you notify us if any of the information you have provided changes at any time. We may also need to share your information for the prevention and detection of fraud and/or other crimes or as the law requires. If you would like to learn more about how Solihull Community Housing uses personal data please refer to our Privacy Notice on the website.