Mary Frances Trust Referral Form

 

1. Please let us know your first name, surname and title (re. Mr, Mrs, Miss)
*

 

2. Please enter your address with postcode: *

 

3. Please may we have your contact details (tel no and/or email address): *

 

4. Reason for your referral? *

 

5. Where did you hear about Mary Frances Trust?

 

6. Are you in receipt of any other mental health service?

 

7. Please let us know which age bracket applies to you: *

16-1819-2526-4041-6465+
 

8. If you are willing to share your gender with us please mark a circle below:

 

9. If you are ok to share your ethnicity with us, please mark one of the circles below:

 

10. Please let us know about any disability you have:

 

11. Are you a carer?

 

12. Please let us know your religion:

 

13. Would you like to receive our newsletter by email? If so please write your email address below - thank you

 

14. In accordance with the Data Protection Act of 1998 and GDPR 2018, all information provided on this referral form and in any further dealings with the Surrey Community Connections and Employment Services will be treated as confidential and will not be disclosed to any third party outside of the Partnership without express consent from the client.
However it is important that you understand that on occasions organisations are obliged to share certain information eg. an individual is at risk to self or others, and may need to inform services such as Local Safeguarding of Vulnerable Adults Team; Child Protection Team; other staff; Service's Regulator(s) and other agencies. Should this need arise the Service will make every effort to discuss this with you prior to any information being shared.

I confirm that I understand the statement above. *

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