Date of Referral

Organisation Making the Referral

Name of Organisation Address   Tel. No. E-mail Contact Person (if applicable)

Client’s Details

Name Address     Tel. No. (State: work/home/mobile)                                        Email:

 

Enquiry Details: brief summary of the enquiry and what help the client is seeking

With reference to potential time limits, please give:-

Date/s of act/s of discrimination      ____________________________________________

Date when client left the job or was dismissed (if applicable)     _______________________

Please list any other important dates or deadlines (e.g. court hearing dates)

Please tick the box confirm that the client is aware you are making this referral and is is expecting us to contact them                         

What is the client’s preferred method of contact?

Please tick this box to state that the client was told that the services of the Discrimination Project are free and funded by the Equality and Human Rights Commission 

Please send this form to: Discrimination Project at Community Law Service (Leicester and County)   Address:  First Floor, Epic House, Charles St. Leicester LE1 3SH Telephone:  0116 2421145                       Fax:  0116 2539305                        E-mail:  enquiries@lma-discriminationproject.org.uk