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Referral Form

Section 1 - Data Protection & Support Services Requred

Data Protection - Please be advised that the data collected on this form is to provide our service.<br />Please read our Privacy Policy available <a href="/privacy-policy">here</a>
Please select the option to continue
Please select the service you wish to access
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Section 2 - Client Personal Details

Please complete your details below. Please ensure you provide us with a current contact telephone number and a contact email address where possible.

Please type your first name.
Please type your last name.
Please enter your age
Please enter your address
Enter your postcode
Please enter a telephone number
Please enter an additional telephone number
Please enter a valid email address

Contact Permissions

Please select the following permissions so we can contact you.

On the Telephone, can we say it is Quiet Waters calling?
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Can we leave a message on the answer service?
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Can we Text?
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Can we email?
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Can we write to the postal address?
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Section 3 - How did you hear of Quiet Waters

I heard about Quiet Waters through:
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Enter how you have heard about Quiet Waters

Section 4 - Availability

Are you able to attend sessions at a time<br />Please note that the more restricted your availability, the longer it can take to get the support you need.
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Daytime - Please advise the days & times you ARE AVAILABLE, you can select multiple.

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Are you able to attend regularly on the same day at the same time?
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Are you happy to accept a Student/Trainee?<br />Note that this is not indicating a person of school leaver age, but many student counsellors are people with work/life experience who are undertaking counselling training/qualifications and counselling hours are required as part of their training.
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Are you happy to accept a male or female counsellor/listener?
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Section 5 - Other relevant information

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I can confirm that I am the person named on this referral form or have completed this form to assist the person named with their full knowledge and consent. I am happy for Quiet Waters Practice Manager or Admin to contact me.
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