Service Referral Form | The Islamic Council of Europe

Service Referral Form

Please complete this form to refer a client for services at IC

Client Details

Name

First

Last

Number

Confirm Email

Please re-enter client’s e-mail address

Hardship Support Fund (HSF) Consideration

Is the client being considered for Hardship Support Fund by you?

Yes

If you ticked Yes above, please choose one of the following:

1. We will cover 100% of the cost towards the client’s fees to Islamic Council

2. We will cover 50% of the cost towards the client’s fees to Islamic Council

3. We will cover some cost towards the client’s fees to Islamic Council (please confirm either % or £ towards fees):3. We will cover some cost towards the client’s fees to Islamic Council (please confirm either % or £ towards fees):

Referee Details

Organisation Name:

Name of person filling form:

First

Last

Phone Number of person filling form:

Client permission:

I confirm that the client has given permission for a referral to be made

Correct Information Declaration:

I confirm that I have read and checked that the above details are correct

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If you are human, leave this field blank.