Referral Form Self-Refer or Refer Someone You Support With The Form Below. Referral Form If you are human, leave this field blank. First Name: * Last Name: * Date of Birth: * Phone No: * Mobile Phone No: Email * Address 1: * Address 2: * Address 3: Town/City: * Postcode: * Do you give us consent to store and use your information in line with GDPR/Data Protection Principles? * Yes No What service are you making a referral to? How would you like us to contact you? * Please describe what is worrying you? * How did you become aware of the service? * Have you ever been a client at The Therapy Hub.Me? * Yes No Has anyone related to you attended The Therapy Hub.Me for Counselling/Any other service? * Yes No If so, do you know the name of the Counsellor/Practitioner? Do you know anyone that works at The Therapy Hub.Me? * Yes No If so who? URGENT INFORMATION YOU THINK WE SHOULD KNOW (Enter N/A if nothing applies) * Suicidal Thoughts? * Yes No Self-Harming behaviours? * Yes No Eating-disorder behaviours? * Yes No Other (E.G. Domestic Violence. Enter N/A if nothing applies) * Submit
