Support Referral Form

If referred or signposted by an organisation, referrer please supply the following details:

We will contact the referrer in the event we cannot make contact with the client

I agree to this information being shared with and between agencies I am currently involved with, including my GP. I understand that this information is being shared with a view to ensuring and assisting the continuity of my care. I am aware that I can withdraw my consent to this information being shared with any or all of these agencies at any time.

As per our safeguarding and confidentiality policies the information you provide is confidential and will not be disclosed to another party unless you disclose information that implies you, another person or a child is at risk, in which case this will be passed to our Safeguarding Lead to decide what action to take– we will endeavour to inform you before any action is taken