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: Mobile/ Phone No: * Email: Address 1: Address 2: * 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? * 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? Please describe what is worrying you? * URGENT INFORMATION YOU THINK WE SHOULD KNOW (Enter N/A if nothing applies) * Are you having Suicidal Thoughts? Yes No Self-Harming behaviours? * Yes No Eating-disorder behaviours? * Yes No Other (E.G. Domestic Violence/Social worker involvement. Enter N/A if nothing applies) * Submit
