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Referral form template

Refer a client, patient, student or customer to another service.

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How to make a referral form

  1. 1

    Check the questions: rename, add or delete any field, or change how it’s answered.

  2. 2

    Add your organisation’s name, a contact line and your logo if you like.

  3. 3

    Choose fillable PDF, printable PDF, Word or HTML, and the paper size.

  4. 4

    Download the referral form and share it, print it or add it to your website.

About this referral form

A referral form passes someone from one service to another with the information the receiving service needs: who the person is, why they’re being referred, how urgent it is and what has been tried already. Doctors, therapists, schools, social workers and businesses with partner programs all use referral forms.

The form includes a consent statement because sharing someone’s details with another organisation usually needs their agreement. Businesses running a customer referral scheme can rename the sections to “Referred by” and “New customer”.

What’s on the referral form

The template has 5 sections and 18 questions. Every one can be renamed, moved or deleted.

  • Person being referred: Full name; Date of birth; Phone; Email; Address
  • Referred by: Name; Organisation; Role; Phone; Email; Date of referral
  • Referred to: Service or professional
  • Referral details: Reason for referral; Urgency (choose one: Routine, Soon (within 2 weeks), Urgent); Support already provided; Other services involved
  • Consent: Agreement: “The person being referred (or their guardian) agrees to this referral and to their information being shared with the service above.”; Signature with date

Tips

  • Include what has already been tried, so the next service doesn’t start from zero.
  • Mark urgent referrals clearly and follow up by phone.
  • Only include the information the receiving service needs.

Four ways to save it

A fillable PDF has typing boxes, tick boxes and choices built in. A printable PDF gives clean boxes and writing lines for pen and paper. The Word file can be edited further, and the HTML code adds the same questions to a website. Browse more form templates, or design a completely different layout in the custom form builder.

Frequently asked questions

Do I need consent to make a referral?

In most health, education and social care settings, yes, except in emergencies or where the law allows otherwise. The template records the person’s consent.

Can I use this for a customer referral program?

Yes. Rename “Reason for referral” to “What they’re interested in”, remove the urgency question and add a reward or code field for the referrer.

Can I get the referral form as a Word document?

Yes. Choose “Word” under “Save as” to download a .docx file you can keep editing in Microsoft Word, Google Docs or LibreOffice.

Can people fill in this referral form on a phone?

Yes. Choose “Fillable PDF” and send the file. It opens in the Files or Drive app on Android, Files on iPhone, and any browser on a computer, where people can type their answers and save the result.

Can I change the questions on the referral form?

Yes. Rename any question, change its answer type (short answer, tick boxes, rating, table and more), move it, or delete it. You can also add whole new sections.

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