Referral Form - Salusbury World

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Home
About Us
- Vision and Mission
- Values
- History
- Funding
- Our Team
- Trustees
What We Do
Our Impact
Get Involved
Join the Salusbury World Family
News
Contact
Policies

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- Step 1 of 3

Name of Referrer *

First

Last

Organisation *

Email *

Client Information

Name of referred person *

First

Last

Current Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Borough *

Telephone *

If you provide a mobile number we will assume it is ok to leave a message/text. Please tick if not.

National Insurance Number *

Email address *

Gender *

Main language spoken *

Interpreter required? *

Any disability/access requirements *

Yes
No

Please specify disability/access requirements *

GP Details

Name of GP *

GP address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Marital Status

Children

Referral Information

Please give a brief reason for the referral. *

Background history (previous diagnoses, hospital admissions, treatment, self-harm or previous suicide attempts *

Prescribed medication: *

Please attach additional information if helpful (e.g. assessment reports)

Click or drag a file to this area to upload.

Name

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Charity no. 1071065

Salusbury World upholds the confidentiality standards required by the Human Rights Act 1998 and ‘common law duty of confidentiality’ along with those required by the General Data Protection Regulator (GDPR). Our full policy can be found here. Salusbury World believes that children and young people have a fundamental right to live and learn in a safe environment and to be protected from any form of harm. Salusbury World believes that it is essential to promote equality of opportunity in all aspects of our work.