Professional Referral Form

The information you enter into this form will be collected and stored by The Living Room. Tick the box below to confirm you understand. (required)

I understand.

Preferred Hub:

Support required for:

Other: please state here

CONFIDENTIAL ONCE COMPLETED

Client Information

Do they live in Hertfordshire? (required)

YesNo

Town: (required)

County of Residence: (required)

Postcode:

Name of Client: (required)

Date of Birth: dd/mm/yyyy (required)

Email Address:

Contact Number:

Reasons for Referral:

Addiction: please provide details

Is the client currently using? (required)

YesNo

Family & Carers: please provide details

Background and Relevant History:

Medication:

Special Access Needs or Disability:

Professional Information:

Organisation Name:

Name of Professional: (required)

Role:

Email Address: (required)

Contact Number:

Completion Date:

Have you obtained consent for this referral from the client? (required)

YesNo

Further Details:

The Living Room trading as ‘The Living Room Hertfordshire’ and ‘Families Living in Recovery’ is a Registered Charity in England and Wales. Registration No. 1080634. CIO Registration 1175541.

Registered Office Address 8-10 The Glebe, Stevenage, Hertfordshire, SG2 0DJ.

www.livingroomherts.org / Facebook: LivingRoomHerts / Twitter: @livingroomherts / Instagram: @livingroomherts

We will always store your personal details securely. We’ll use them to provide the service that you have requested, and communicate with you in the way(s) that you have agreed to. Your data may also be used for analysis purposes, to help us provide the best service possible. For full details see our Privacy Policy. https://www.livingroomherts.org/privacy-policy

Your Data (Required)

I (the client) give consent for my personal data to be handled by The Living Room as explained in the Privacy Policy.

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