Referral form: pass a name on with the details attached

Updated 2026-10-30

Referrals often arrive as a hallway comment or a forwarded email. The name is there, the number is not, and nobody says why. I would rather one link collect who refers, who is referred and the reason. Use it as a referral form template for any practice or team.

How it works

The referrer gives their name, organisation and contact details.
They name the person they are referring and how to reach them.
They say how they know that person, what the person needs and how soon.
They confirm the person agrees to be contacted.

A sample chat with the referrer's AI

"Who are you referring?" Then "How can we reach them?" Then "Why are you referring them?" The AI shows the answers, asks "Send it?" and submits only after a yes. See agent-fillable forms.

Good to know

Keep the reason short. Check your local privacy rules before collecting health data. This is a form, not medical advice, so clinical detail belongs in the secure system you already use. Browse forms for accountants, lawyers and consultants, forms for clinics and healthcare and forms for agencies and freelancers. A quote request form fits when the referred person wants a price, and a testimonial collection form asks happy clients for words that bring in more referrals.

Questions

Why is a consent box required?

It records that the person being referred knows their details are shared and agrees to be contacted. You keep that answer in the CSV next to the contact details.

How do I thank the people who refer?

Filter the CSV by the referrer_email column to see who sends you the most people. Thank them yourself, because the form does not email the people who fill it.

Can I use the same form for different services?

Yes. The need and reason questions are free text. Sort the CSV by the need_in_one_line column and route each row to the right person on your team.

Try the form

Live demo · nothing is saved

Refer someone to us

Thank you for passing a name on. Tell us who they are and why you thought of us. Please share only what we need to make contact.

Use this template All templates

Or paste the JSON

Give this to your AI. It needs the AI Form API MCP server or an API key. It makes the form and sends you the link.

text

Create this form with the AI Form API create_form tool (or POST https://aiformapi.com/v1/forms with my API key). Then reply with the public_url.

{
  "title": "Refer someone to us",
  "description": "Thank you for passing a name on. Tell us who they are and why you thought of us. Please share only what we need to make contact.",
  "fields": [
    {
      "id": "referrer_name",
      "label": "Your name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "referrer_organisation",
      "label": "Your organisation, if any",
      "type": "short_text",
      "max_length": 150
    },
    {
      "id": "referrer_email",
      "label": "Your email",
      "type": "email",
      "required": true
    },
    {
      "id": "referrer_phone",
      "label": "Your phone",
      "type": "phone"
    },
    {
      "id": "referred_name",
      "label": "Name of the person you are referring",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "referred_contact",
      "label": "Email or phone for that person",
      "type": "short_text",
      "required": true,
      "max_length": 200
    },
    {
      "id": "relationship_to_referred",
      "label": "How do you know them?",
      "type": "single_choice",
      "options": [
        "Client or customer",
        "Colleague",
        "Friend or family",
        "Other professional contact"
      ]
    },
    {
      "id": "need_in_one_line",
      "label": "What do they need help with?",
      "type": "short_text",
      "max_length": 300
    },
    {
      "id": "referral_reason",
      "label": "Why are you referring them?",
      "type": "long_text",
      "required": true,
      "help": "Keep it short. Leave out details we do not need to make contact.",
      "max_length": 1500
    },
    {
      "id": "referral_urgency",
      "label": "How soon should we reach out?",
      "type": "single_choice",
      "options": [
        "Urgent",
        "Within a few days",
        "No rush"
      ]
    },
    {
      "id": "person_agrees_to_contact",
      "label": "This person knows I am sharing their details and agrees to be contacted",
      "type": "checkbox",
      "required": true
    },
    {
      "id": "update_referrer",
      "label": "Please let me know once you have contacted them",
      "type": "checkbox"
    }
  ]
}

Or call the API

bash

curl -X POST https://aiformapi.com/v1/forms \
  -H "Authorization: Bearer $AIFORMAPI_KEY" \
  -H "Content-Type: application/json" \
  -d '{"title":"Refer someone to us","description":"Thank you for passing a name on. Tell us who they are and why you thought of us. Please share only what we need to make contact.","fields":[{"id":"referrer_name","label":"Your name","type":"short_text","required":true,"max_length":150},{"id":"referrer_organisation","label":"Your organisation, if any","type":"short_text","max_length":150},{"id":"referrer_email","label":"Your email","type":"email","required":true},{"id":"referrer_phone","label":"Your phone","type":"phone"},{"id":"referred_name","label":"Name of the person you are referring","type":"short_text","required":true,"max_length":150},{"id":"referred_contact","label":"Email or phone for that person","type":"short_text","required":true,"max_length":200},{"id":"relationship_to_referred","label":"How do you know them?","type":"single_choice","options":["Client or customer","Colleague","Friend or family","Other professional contact"]},{"id":"need_in_one_line","label":"What do they need help with?","type":"short_text","max_length":300},{"id":"referral_reason","label":"Why are you referring them?","type":"long_text","required":true,"help":"Keep it short. Leave out details we do not need to make contact.","max_length":1500},{"id":"referral_urgency","label":"How soon should we reach out?","type":"single_choice","options":["Urgent","Within a few days","No rush"]},{"id":"person_agrees_to_contact","label":"This person knows I am sharing their details and agrees to be contacted","type":"checkbox","required":true},{"id":"update_referrer","label":"Please let me know once you have contacted them","type":"checkbox"}]}'

JSON definition

json

{
  "title": "Refer someone to us",
  "description": "Thank you for passing a name on. Tell us who they are and why you thought of us. Please share only what we need to make contact.",
  "fields": [
    {
      "id": "referrer_name",
      "label": "Your name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "referrer_organisation",
      "label": "Your organisation, if any",
      "type": "short_text",
      "max_length": 150
    },
    {
      "id": "referrer_email",
      "label": "Your email",
      "type": "email",
      "required": true
    },
    {
      "id": "referrer_phone",
      "label": "Your phone",
      "type": "phone"
    },
    {
      "id": "referred_name",
      "label": "Name of the person you are referring",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "referred_contact",
      "label": "Email or phone for that person",
      "type": "short_text",
      "required": true,
      "max_length": 200
    },
    {
      "id": "relationship_to_referred",
      "label": "How do you know them?",
      "type": "single_choice",
      "options": [
        "Client or customer",
        "Colleague",
        "Friend or family",
        "Other professional contact"
      ]
    },
    {
      "id": "need_in_one_line",
      "label": "What do they need help with?",
      "type": "short_text",
      "max_length": 300
    },
    {
      "id": "referral_reason",
      "label": "Why are you referring them?",
      "type": "long_text",
      "required": true,
      "help": "Keep it short. Leave out details we do not need to make contact.",
      "max_length": 1500
    },
    {
      "id": "referral_urgency",
      "label": "How soon should we reach out?",
      "type": "single_choice",
      "options": [
        "Urgent",
        "Within a few days",
        "No rush"
      ]
    },
    {
      "id": "person_agrees_to_contact",
      "label": "This person knows I am sharing their details and agrees to be contacted",
      "type": "checkbox",
      "required": true
    },
    {
      "id": "update_referrer",
      "label": "Please let me know once you have contacted them",
      "type": "checkbox"
    }
  ]
}