Suffolk Mind Connect referral form - Primary Care Network

    Fields marked with an * are required

    Client information

    Background 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


    I declare that the information provided about the client is accurate to the best of my knowledge.

    The client authorises Suffolk Mind to store personal information related to them and the service 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.