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Referral Form
Ethnic background:
Black or Black British
African
Caribbean
Other Black or Black British background
Mixed White
White and Black Caribbean
White and Black African
White and Asian
Other Mixed White
Asian or Asian British
Indian
Pakistani
Bangladeshi
Other Asian
Full Name
DOB
Gender
Male
Female
Prefer not to Say
Address
Telephone Number
Mobile Number
Email Address
Current diagnosis and any other relevant information: The issue must be in relation to improving their wellbeing.
How does the person communicate?
English
Other spoken language (please specify)
British Sign Language
Words/pictures/Makaton
Gestures/facial expressions/vocalisations
No obvious means of communication
Other
Does the person have a disability or impairment? (Optional)
Yes
No
Consent:
Because of the GDPR (2018), we need signed authorisation to say that individuals accessing our service agree to us holding personal information (including the information on this form)
Does the person have capacity to consent to the referral?
Yes
No
If yes, has consent been obtained?
Yes
No
If you are referring on behalf of someone else, please provide your details below:
Name
Email Address
Telephone
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