Organisation referral form

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Name of Client
Gender
if they have one
please tell us how long you have been in recovery
IE; CGL , the hospital, GP, rehab
Do they have a diagnose mental health condition
If you answered yes to the previous question please tell us what condition. If you answered no but still have mental health please tell us what.
Disclosure of information
Disclosure of information I understand the information that I have given today will be stored in a paper form as well as electronically. It has been explained to me that it will be stored securely in line with data protection policy. This information will only be stored for as long as necessary and will only be shared with your consent and in line with our safeguarding policy.
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