Mums Matter Referral Form


    Fields marked with an * are required



    Please choose which service/s you require*

    Mums Matter locations*

    Counselling locations*

    Full address*

    Postcode*

    Contact number*

    GP Surgery*

    Mental health diagnosis and/or reason for referral*

    Number of children and their ages*

    Do you have support from any other organisation? E.g. health visitor*

    What best describes your gender identity?*

    Is your gender identity the same as the sex you were assigned at birth?*

    Sexual Orientation*

    Ethnicity*

    Nationality*

    Religion*

    Employment status*

    Do you have an activity limiting disability under the Equality & Diversity Act 2010?*

    We communicate with our clients by email, telephone, text and letter (which will be sent to the address supplied on this referral form). I am happy for Suffolk Mind to communicate with in the following ways*

    Are you happy for other services within Suffolk Mind with whom you are registered to exchange relevant wellbeing information?*

    Confidentiality & Data Protection

    Suffolk Mind is committed to maintaining client confidentiality. All information about you is held securely. We will never sell or share your personal information except with trusted partners and suppliers who work with us on or on our behalf to deliver our services. You have the right to request access to a copy of the personal information that we hold about you.

    For further information please view our Privacy Policy


    Declaration

    I declare that the information provided by me is accurate to the best of my knowledge.

    If I choose to go ahead with my referral through this service, I hereby authorise Suffolk Mind to store personal information related to me and my client and the service I/they receive.

    If you are happy to accept the above terms and conditions please tick the following box and click on the button marked submit.