Freeing Minds Referral Form
This form is a referral to The Vine Community Centre's Freeing Minds talking therapy project.
Information on this form will remain confidential. Records are kept in accordance with the Data Protection Act  2018 & GDPR. You may request access to any records held by us by applying in writing to Freeing Minds c/o The Vine Community Centre.
Email *
Todays Date *
MM
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DD
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Client Name *
Client Phone Number *
Client Email *
Presenting Issues *
Required
Do you feel you have complex mental health issues? *
Required
Presenting Issues that you would like to discuss (Please give brief details) *
Are presenting issue COVID19 related *
Required
Do you have a criminal Record *
Do you pose a risk to workers *
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