Lambeth

About you

Contact details

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

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

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.

Your GP

Please note, your GP details are required in case we have serious concerns for your health and wellbeing during your programme of support. In exceptional circumstances our counsellor/support worker may contact your GP to alert them to a matter of concern or perceived (non-emergency) risk to you. This would normally be done in discussion with you and with your agreement, but in certain circumstances where it was not possible to contact you or the risk was deemed to be high, we may contact them without your agreement.

Support

Please give details.

Please tick all that apply.