Self referral form to access Social Prescribing or Counselling Service Support

Title*

First name*

Last name*

Date of birth*

Gender

Ethnicity

Sexuality

Languages spoken (if not English)

Address*

Postcode*

Contact details

email*

Landline

Mobile

Other

Alternative contact details

Alternative contact name

Relationship with Client

Address

Postcode

Landline

Mobile

Other

Who should be the first point of contact? Client Alternative contact

Service interested in

Adult's Social Prescribing Service

Children’s GR8 minds Social Prescribing Service

Children’s GR8 minds Counselling Service

Name of GP Practice*

Reason for referral

Consent notice

The information provided on this form will be held on the WACA GP Federation database. Under the Data Protection Act (1998), the Data Protection (Processing of Sensitive Personal Data) order 2000 and General Data Protection Regulation (25 May 2018), you have the right to access this information. Under this act & with your consent the information on this form will be shared with WACA GP Federation Practices in line with GDPR guidelines. You can withdraw consent at any time you wish. If you would like a copy of the privacy notice please ask a member of staff or visit our website.

Consent given? Yes No

Consent date

Self referral form to access Social Prescribing or Counselling Service Support

Thank you for completing the form.

WACA LTD

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