This is a test referral form. Data entered into this form will not be recorded or used for real referrals. If you are referring someone else, please fill in their details for each question other than where "the referrer" is mentioned.
Please read the following privacy script
This project is part of a charity called Humankind.
Our top priorities are your safety and helping you achieve your goals with us. To do this, we need to keep some information like your basic contact details and more sensitive information like your health details. This is called a “legitimate interest” to use your information.
We keep your information safe and only share it with others if there is a good reason. Most of the time we ask your consent before we share, and we will complete our consent process with you during your first appointments with us. Occasionally, we may need to share your information without seeking your consent if we are worried that you or someone else could be in danger. This is called safeguarding and is a UK law that all health and social care organisations must follow. We will usually be able to tell you what we have shared and to whom. We will provide a factsheet with examples when we meet.