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PMH Referral Form

Please complete the form below either for yourself or on behalf of a client. If parental consent hasn't been obtain or the referral has not been discussed with the client we are unable to accept this referral

Who is making this referral?
Type of service
Please select an option from the list below
  • Counselling
  • Advocacy
  • Mentoring
  • Other Services
  • Enquiry
Preference for sessions
How would you like to do your sessions?
  • Face to face sessions
  • Virtual/online
  • Telephone/texting
  • No preference
Client gender
Client ethnicity
Client E-mail address
  • {name}
Client Address
  • {name}
Referrer email address
  • {name}
What outcomes are you hoping for?
  • {name}
Additional information
what is your enquiry or referral relating to?
  • {name}
Do you consent for us to store personal information in accordance with GDPR guidelines?
Agreement
This is an Information Sharing Agreement. Precious Counselling and Mentoring (CIC) and Precious Moments and Health Ltd Group companies will store and maintain data in accordance with the Data Protection Act (1998) guidelines and GDPR legislation. We will take all reasonable steps to ensure that your data will be handled safely, securely and in accordance with your rights, our obligations and the obligations of the third party under GDPR and the law. Please refer to our Privacy Policy on our website for further information

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