17
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Services Referral Form
Name
Address
Home Phone Number
Mobile Phone Number
Email
Date of Birth
MM
/
DD
/
YYYY
GP Surgery
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33
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Services Referral Form
Next of Kin details
First / Last name
Relationship to you
Phone number
Email address
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50
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Services Referral Form
Please choose which service(s) you require
Please select
Counselling - Under 18
Counselling - Over 18
Counselling - Student Package
Please select
If you have any time restrictions, let us know:
How did you hear about our service?
Please select
GP
Social Media
Website
Friend/Family
Mental Health Support
National Mind
Other
Please select
Mental health diagnosis and/or reason for referral:
We communicate with our clients by email, telephone, zoom ( remote counselling service) and letter (which will be sent to the address supplied on this referral form).
“I am happy for SECE Mind to communicate with me in the following ways"
Email
Letter
Telephone
Zoom (I am happy to consent to video counselling)
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67
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Services Referral Form
What best describes your gender identity?
Female
Intersex
Male
Non-Binary
Other
Prefer Not To Say
Do you identify as Transgender?
Yes
No
Prefer Not To Say
Sexual Orientation
Heterosexual / Straight
Homosexual / Gay / Lesbian
Bisexual
Pansexual
Prefer To Self Describe
Prefer Not To Say
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83
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Services Referral Form
Ethnicity:
Please select
White - English / Welsh / Scottish
White - Irish
White - Irish Traveller
White - Eastern European
White - any other white background
Dual heritage - White and Black Caribbean
Dual heritage - White and Black African
Dual heritage - White and Asian
Any Other Mixed
Asian - Indian
Asian - Pakistani
Asian - Bangladeshi
Asian - Chinese
Asian British
Asian - Any other
Black African
Black Caribbean
Black British
Arab
Any other Ethnic Group
Prefer not to answer
Please select
Preferred Language
Religion
Please select
Buddhist
Christian (any denomination)
Hindu
Jewish
Muslim
Sikh
No Religion
Prefer Not To Say
Please select
Employment Status:
Employed - Full Time
Employed - Part Time
Full Time Parent/Carer
Unemployed
Student
Retired
Do you consider yourself to have an activity limiting disability under the Equality & Diversity Act 2010?
No
Yes - Hearing
Yes - Vision
Yes - Mobility
Yes - Learning Need
Yes - Mental Health Condition
Yes - Self Describing
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Services Referral Form
Confidentiality & Data Protection
Privacy Notice:
This form contains personal and sensitive ('special category') data which will be processed and stored in accordance with Information Governance policies, the Data Protection Act 2018 and Articles 6(1)(e) and Articles 9(2)(h) of the General Data Protection Regulation (GDPR). The information you provide will be shared confidentially within the organisation and stored securely and used for the purposes of processing and providing a service to you.
Declaration
I confirm the information I have provided is correct and understand how it will be used.
If I choose to go ahead with my referral through this service, I hereby authorise SECE Mind to store personal information related to me and the service I receive.
I am happy to accept the above terms and conditions.
Signature
Clear
Verification
Apply
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