Support Services Referral Form

Kaleidoscope Plus Group SORT Floating Support Service offers short-term housing related support for people age 18+ living in Sandwell and are suffering a mental health difficulty.

About You

Enter the types of pets you have, or leave blank if this doesn't apply.
Please provide as much detail as you can.
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Please provide as much detail as you can.

About Your Needs

Please tick what type of support you require from us to assist your independent living:
Please provide as much detail as you can.
Please provide as much detail as you can.
Please provide as much detail as you can.

About Your Current Support Network

Please tick all support providers you have access to,
Please provide as much detail as you can.

Risk Assessment

Please tick all the questions that you would answer 'yes' to. If there is something you would like to add, please tick 'other' and give us a brief description

Sign and Referrer Information

I hereby authorise Kaleidoscope Plus Group Support Service to contact and request information and to act on my behalf with agencies and authorities as necessary.

Referrer's Details

If this referral has been completed on behalf of the client, please complete below:

Privacy Notice

We are committed to respecting your privacy. This notice is to explain how we may use personal information we collect before, during and after your relationship with us. This notice explains how we comply with the law on data protection, what your rights are and for the purposes of data protection we will be the controller of any of your personal information.

This notice applies to you if you use any service provided by the Kaleidoscope Plus Group:

References to we, our or us in this privacy notice are to The Kaleidoscope Plus Group, 321 High Street, West Bromwich, West Midlands, B70 8LU (Registered charity number 1096473) We have not appointed a Data Protection Officer to oversee our compliance with data protection laws as we not required to do so but our Chief Executive has overall responsibility for data protection compliance in our organisation.

Contact details are set out in the "Contacting us" section at the end of this privacy notice.

1. PERSONAL INFORMATION WE MAY COLLECT FROM YOU
When you receive a service from us, you may provide us with or we may obtain personal information about you, such as information regarding your personal contact details that allows us to contact you directly such as name, title, email.

addresses and telephone numbers;
date of birth; gender; records of your interactions with us such as telephone conversations, emails and other correspondence; details of next of kin, family members, records of your attendance at any activities or events hosted by us; images in video and/or photographic form and voice recordings. marketing preferences

2. SPECIAL CATEGORIES OF PERSONAL INFORMATION
We may also collect, store and use the following “special categories” of more sensitive personal information regarding you: information about your race or ethnicity, religious beliefs and sexual orientation;
information about your health, including any medical condition, health and sickness
records, medical records and health professional information.

We may not collect all of the above types of special category personal information
about you. In relation to the special category personal data that we do process we do so on the basis that the processing is necessary for reasons of substantial public interest, on a lawful basis; it is necessary for the establishment, exercise or defence of legal claims; it is necessary for the purposes of carrying out the obligations and exercising our or your rights in the provision of a service from us it is a contractual requirement in order for us to receive funding from those who fund our services based on your explicit consent. In the table below, we refer to these as the “special category reasons for processing of your personal data”. We may also collect criminal records information from you. For criminal records history, we process it on the basis of legal obligations or based on your explicit consent.

3. WHERE WE COLLECT YOUR INFORMATION
We typically collect personal information about the users of our service when you either refer yourself to one of services or when a referral is made on your behalf, when you make a query and/or complaint or when you correspond with us by phone, e-mail or in some other way. If you are providing us with details of next of kin, family members and emergency contacts they have a right to know and to be aware of what personal information we hold about them, how we collect it and how we use and may share that information. Please share this privacy notice with those of them. They also have the same rights as set out in the “Your rights in relation to

4. USES MADE OF THE INFORMATION
The  below table describes the main purposes for which we process your personal information, the categories of your information involved and our lawful basis for being able to do this.

Purpose Personal information used Lawful basis
To administer and manage our relationship with you and to provide you with the support service required All contacts and support details, and records of your interactions with us. This is necessary to enable us to properly manage and administer a
support service to you
To send you information about our services and facilities All contacts and support details, and records of your interactions with us.  This is necessary to enable us to properly manage and administer a
support service to you
To send you other marketing information we think you might find useful or which you have requested from us including our newsletters,
information about our services, events, participation in fundraising
activities and other service
information
All contact and support details and marketing preferences Where you have given us your explicit consent to do so
To answer your queries or
complaints
Contact details and records of your interactions with us We have a legitimate interest to provide
complaint handling services to you in
case there are any issues with the services we have provided you
Retention of records All the personal information we collect We have a legitimate interest in retaining records whilst they may be required in relation to complaints or claims. We need to retain records in
order to properly administer a service to
you and in some cases, we may have a legal or regulatory obligations to retain records.We process special category
personal data on the basis of the “special category reasons for
processing of your personal data” referred to in the section 2 above.For criminal records history we process
it on the basis of legal obligations or based on your explicit consent.
The security of our IT systems Your usage of our IT systems and online portals We have a legitimate interest to ensure that our IT systems are secure
To conduct data analytics studies to better understand activity and event attendance and trends within our services Records of your attendance at any activities and events hosted by us We have a legitimate interest in doing so to ensure that our services are targeted and relevant
For the purposes of promoting the organisation, our activities, events and services Images in video and/or photographic form Where you have given us your explicit consent to do so
To comply with health and safety requirements Records of attendance We have a legal obligation and a
legitimate interest to provide you and other members of our organisation with a safe environment in which to
participate in sport
To make decisions about your progression and development through any service pathway and to
assist with the delivery of an effective service
All information about the support provided to you, your interactions with
us and information about your health
We have a legitimate interest in doing so to ensure that our services are targeted and relevant and that you are getting the best possible support
service. In some cases we also have to provide this information to our
commissioners
To use information about your physical or mental health or disability status, to ensure your health and safety and to assess your
eligibility for our services
Health and medical information We process special category personal
data on the basis of the “special category reasons for processing of personal data” referred to in section 2 above.
For the purposes of equal
opportunities monitoring
Name, title, date of birth, gender, information about your race or ethnicity,
health and medical information and
performance data
We have a legitimate interest to promote a service that is inclusive, fair and accessible.

We process special category personal
data on the basis of the “special category reasons for processing of your
personal data” referred to in section 2 above.

For some of your personal information you will have a legal, contractual or other requirement or obligation for you to provide us with your personal information. If you do not provide us with the requested personal information, we may not be able to provide you with a service or we may not be able to properly perform our contract with our commissioners or comply with legal obligations. We may therefore have to terminate the provision of a service to you. For other personal information you may not be under an obligation to provide it to us, but if you do not provide it then we may not be able to properly provide a service to you.

Where you have given us your consent to use your personal information in a particular manner, you have the right to withdraw this consent at any time, which you may do by contacting us as described in the “Contacting Us” section below.

Please note however that the withdrawal of your consent will not affect any use of the data made before you withdrew your consent and we may still be entitled to hold and process the relevant personal information to the extent that we are entitled to do so on bases other than your consent. Withdrawing consent may also have the same effects as not providing the information in the first place, for example we may no long be able to provide a service to you.

5. DIRECT MARKETING

Email, post and SMS marketing: from time to time, we may contact you by email, post or
SMS with information about events, activities and services we believe you may be interested in. We will only send marketing messages to you in accordance with the marketing preferences you set. You can then let us know at any time that you do not wish to receive marketing messages by writing to us or emailing us at [email protected]. You can also unsubscribe from our marketing by clicking on the unsubscribe link in the marketing messages we send to you.

6. DISCLOSURE OF YOUR PERSONAL INFORMATION

We share personal information with the following parties:

  • Any party approved by you.
  • To our funders.
  • Other service providers: for example, agencies that may make a referral on your behalf and agencies with whom we work to ensure you receive a holistic service. This may include but is not limited to, local authorities, social services, other health providers
    with whom we work in partnership, and clinical commissioning groups

The Government or our regulators: where we are required to do so by law or to assist with their investigations or initiatives.

Police, law enforcement and security services: to assist with the investigation and
prevention of crime and the protection of national security. We do not disclose personal information to anyone else except as set out above.

7. TRANSFERRING YOUR PERSONAL INFORMATION INTERNATIONALLY

The personal information we collect is not transferred to and stored in countries outside of the UK and the European Union.

8. HOW LONG DO WE KEEP PERSONAL INFORMATION FOR?

The duration for which we retain your personal information will differ depending on the type of information and the reason why we collected it from you. However, in some cases personal information may be retained on a long-term basis: for example, personal information that we need to retain for legal purposes will normally be retained in accordance with usual commercial practice and regulatory requirements. Generally, where there is no legal requirement we retain all physical and electronic records for a period of 6 years after your last contact with us.

Exceptions to this rule are:

  • CCTV records which are held for no more than 30 days unless we need to preserve the records for the purpose of prevention and detection of crime;
    Information that may be relevant to personal injury claims, or discrimination claims may be retained until the limitation period for those types of claims has expired.
  • For personal injury or discrimination claims this can be an extended period as the limitation period might not start to run until a long time after your last contact with us.

It is important to ensure that the personal information we hold about you is accurate and up-to date, and you should let us know if anything changes, for example if you change your phone number or email address.

You can contact us using the details set out in the "Contacting us" section below.

9. YOUR RIGHTS IN RELATION TO PERSONAL INFORMATION

You have the following rights in relation to your personal information:

the right to be informed about how your personal information is being used;
the right to access the personal information we hold about you; the right to request the correction of inaccurate personal information we hold about you; the right to request the erasure of your personal information in certain limited circumstances; the right to restrict processing of your personal information where certain requirements are met; the right to object to the processing of your personal information; the right to request that we transfer elements of your data either to you or another service provider; and
the right to object to certain automated decision-making processes using your personal information.

You should note that some of these rights, for example the right to require us to transfer your data to another service provider or the right to object to automated decision making, may not apply as they have specific requirements and exemptions which apply to them and they may not apply to personal information recorded and stored by us. For example, we do not use automated decision making in relation to your personal data. However, some have no conditions attached, so your right to withdraw consent or object to processing for direct marketing are absolute rights. Whilst this privacy notice sets out a general summary of your legal rights in respect of personal information, this is a very complex area of law. More information about your legal rights can be found on the Information Commissioner’s website at https://ico.org.uk/for-the-public/.

To exercise any of the above rights, or if you have any questions relating to your rights, please contact us by using the details set out in the "Contacting us" section below. If you are unhappy with the way we are using your personal information, you can also complain to the UK Information Commissioner’s Office or your local data protection regulator. We are here to help and encourage you to contact us to resolve your complaint first.

10. CHANGES TO THIS NOTICE

We may update this privacy notice from time to time. When we change this notice in a material way, we will update the version date at the bottom of this page. For significant changes to this notice we will try to give you reasonable notice unless we are prevented from doing so. Where required by law we will seek your consent to changes in the way we use your personal information.

11. CONTACTING US

In the event of any query or complaint in connection with the information we hold about you, please email [email protected] or write to us at 321 High Street, West Bromwich, B70 8LU West Midlands, B66 1BB

Version dated (1) May 2018

I confirm that I have read and understood the Kaleidoscope Plus Group's 'Privacy Notice for Users of our Services.

I give my consent for the Kaleidoscope Plus Group to collect and use my information as described in the notice and am aware that I can withdraw this consent at any time. I am also aware that withdrawal of consent may lead to the termination of services from the Kaleidoscope Plus Group in some circumstances.

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