Your Situation

Please select the reason for completing this form.*

I need support for myself

I am referring someone else

Referrer

Please enter your own details here as the person making the referral.

Referring organisation*

Referrer name*

Referrer phone number*

Referrer email address*

Has consent been given for sharing personal information?*

Yes

Verbal agreement

Has this individual agreed to support?*

Yes

Personal Details

Please enter details of the person seeking support

First name*

Last name*

Date of birth*

Gender*

Other gender

Contact

Phone number*

We will only use this to contact you about the service you are requesting.

How can we use this phone number?

Text messages

Phone calls

Leave messages (voicemail)

Email address*

We will only use this to get in touch about your referral.

Can we send emails?

Yes

Address*

Please note, your postal address is required in case of emergency during your support sessions. In exceptional circumstances we may be required to call emergency services to your home. Your counsellor/support worker would only do this if they believed that there was immediate risk of harm to you or someone else at your home.

Town*

Postcode*

Can we send letters to this address?

Yes

Preferred contact method

Best time to contact

GP Practice Name*

GP Practice Address*

GP Practice Town*

GP Practice Postcode*

GP Practice Phone number*

CGL Gateshead

Your Situation

Referrer

Personal Details

Contact

Referral