Employer support request form

If your colleague needs support, to help them through a crisis or with a particular area of their mental health, physical health or wellbeing, please complete the form. This goes directly to our support team and one of our advisors will be in touch once they have received it.

Ben collects personal information (data) from you when you apply for support from us. We are required by law, under the GDPR, to have your consent to do this.

We will store the information safely and securely. Once this information is no longer needed we will destroy it.

Simply complete the short form below and read the consent statement. If the employee is happy with this, please tick the box and press submit. You will then each receive an email from us to confirm that we have received the completed form.

Thank you!

Employer referral consent form

Employer

Employer company name *

Employer full name *

Employer contact email *

Employer contact number

Individuals

Individual's full name *

Individual's email address *

Individual's contact number *

Address *

Postcode *

Date of birth *

Referral and consent

Please state the reason for referral *

You can withdraw your consent at any point by contacting Ben. For further information please see our privacy policy: www.ben.org.uk/ben-policies/privacy-policy/