If you wish to refer a recipient, please fill in the form below; please be as specific as possible when giving details regarding the person being referred. We do not ask for the age of the recipient but we do not accept recipients aged 17 years or younger.

The recipient’s data is held in line with the GDPR and we hold data on clients under “legitimate interest”. For more information, please read our Privacy Policy.

Required for the annual report to the Charities Commission.
To be completed if the Client has a partner living with them.
We assume that the client lives in the area of Woking, Surrey.
Please give any details that will help us to meet the recipient’s needs; this can include reasons for referral, and potential deadlines, cultural issues, etc. Please be as specific as possible. Please also make us aware of any needs or risks to Besom that we need to know about.
Please describe any access details that we should be aware of when visiting (e.g. third floor in a block of flats with no lift, no parking, etc.).
What is your client’s Covid-19 status? Are they self-isolating, in quarantine, shielding, etc.?