Self Referral Form

Data protection:

  • Any information you provide is secure and confidential.

  • The feedback you provide from this form will be shared anonymously with our commissioner, the Department of Health and Social Care.

  • This means we will tell them what you say but they we will not provide them with your personal information such as your name or address.

  • If you provide us with your contact informaiton such as your phone number or email, we may contact you about our upcoming events and services.


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Details of person being referred

We may contact you about future events.