This form is for you to use to refer a client to CAK or another member agency of kiaa. We record information about the client and their problem so that we can help them and so that our colleagues can check later in case we have missed anything. We also use the issues that clients come to us about to improve our service and to tackle wider issues in society in a way that does not directly identify them. We keep what we are told safe and confidential and the client can always decide what they share with us. If you or the client needs more information about this please email us at:
You need to have the client's consent BEFORE you make a referral using this form
Please provide your email address/contact number
So that we can confirm the referral once received
What is the client's name?
What is the client's full address?
What is the client's date of birth?
Please provide the client's contact details?
So that we can contact them when we have an appointment for them
Please provide the reason for your referral
If you would like to provide more details please select 'other'
If yes, when is the deadline?
The client requires assistance on:
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