Managed Referral Form

We believe that proactive employee support benefits everyone.

If you’re in a supervisory role or have management responsibility (such as a manager, HR, or licensee) and have concerns about a staff member facing work or personal difficulties, but they’re hesitant to call our helpline, you can refer them to us using the form below. Just make sure they consent to sharing their details so we can contact them directly.

All support remains confidential. While we won’t share details of what’s discussed, we can confirm if the staff member has accessed the support. The only exceptions are if they agree to share more or if there’s a risk of harm, in which case we’ll aim to speak with them first.

If you’d like to talk through any people management concerns or are worried about a staff member, call us at 0800 801 0550 (option 4), or contact us using the management enquiry form.

Referrer’s Information

Referring Person’s First Name*

Referring Person’s Last Name*

Job title*

Work telephone number*

Mobile telephone number*

Email Address*

Reasons for the referral*

By ticking this box, I can confirm that I have the employee’s consent for the Licensed Trade Charity to make contact with the employee directly. *

Employee’s Information

Employer*

Please select your current or most recent employer by typing their name. If your employer isn’t on the list, please type ‘Independent’.

Sorry, you are not eligible for financial support.

First Name of Employee*

Last Name of Employee*

Job Title*

Postcode

Address First Line

Address Second Line

City

County

Work Address

Preferred Contact Phone Number – PLEASE provide least two contact routes.

Mobile telephone number*

Can we leave a message on this phone number?*

Home telephone number

Can we leave a message on this phone number?

Work telephone number

Can we leave a message on this phone number?

Email Address*

Contact times preferred (please state times and dates)

I agree to let the Licensed Trade Charity and their associated Helpline, CiC, contact me using the details I have provided. I understand that my information will not be shared with any other third parties and will be securely stored with the Licensed Trade Charity. *

Remember, you can always reach out to us via our helpline, 24 hours a day, seven days a week. Give us a call on 0808 801 0550, and we’ll do our best to assist you.