Client Referral Form

Please fill out the form below. For any fields that are not applicable please enter N/A.

Name:
Email Address:
Date of Birth
Marital Status
Are you Employed?


In receipt of Benefits


Ethnic Origin
Address
Home Phone
OK to leave message?


Mobile Phone
OK to leave message on Mobile?


Reason for Referral
Please give details of any identified risk issues
Current Medication
Is there any substance history, past or present, if so please list history/problems and amount. Substance relates to alcohol, drugs and prescribed drug addiction, misuse and habits etc.
Please give details of any current/previous involvement with GP/Health Professional/other services including dates if known.
GP Practice & Registered Doctor
Referrer's Name
Referrer's Title
Referrer's Organisation
Referrer's Position
Date of Referral
Where did you hear about our service

Using your personal information

Personal information which you supply to us may be used in a number of ways, for example:

  • We will use the information you give to help provide the services/products you have requested that we supply to you.
  • From time to time information may need to be accessed by our website and hosting providers to ensure the smooth running of the services we provide.
  • We will not disclose any information to any company outside the above mentioned scenarios except to help prevent fraud, or if required to do so by law

For further information on how your information is used, how we maintain the security of your information, and your rights to access information we hold on you, please visit https://www.counsellorstogether.co.uk/terms

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