Need support?  We’re here to help, so please get in touch with us.

Please enter your support requirements in the form below.


Personal information submitted through this form will be treated in accordance with the General Data Protection Regulation 2016, and used only for purposes required for the referral process. AFG will never pass on personal details, or use them for other purposes, without consent, and you have the right to revoke your consent and request the deletion of your details at any time. Click here for more information.

Your Name (Person referring)*

Your Position/Relationship*

Your Address

Your Telephone Number

Your Email

Name of person being referred*

Likes to be known as

Date of birth (dd/mm/yyyy)

Temporary address

Permanent address

Telephone Number

Their Email

Marital status


Person aware of referral

Preferred language

Interpreter required

Preferred communication

Legal Status

Other Legal Status - please specify

Ethnic background

Other Ethnic background - please specify

Other significant people - Name, Relationship, Contact Details

Reason for referral

Primary support needs*

Other - please specify

Secondary support needs

Other - please specify

Potential hazards for assessor to be aware of (e.g. potential violence, dangerous dog, isolated property

Type of support/service required

Other - please specify