I confirm that 1in4 People Ltd Advocacy has been instructed by myself to do this work. I agree to 1in4 People Ltd storing my information on a secure database and filing system. I confirm that I understand that 1in4 People Ltd will uphold the Confidentiality Policy and the Data Protection Act with regard to my personal information. ___________________________________ __________________________________ CLIENT SIGNATURE DATE THE REFERRER (leave blank if signed by client) ___________________________________ ________________________________ SIGNATURE DATE ___________________________________ PRINT NAME To ensure that your referral is with promptly ensure that you complete ALL relevant sections and sign before returning. We accept an unsigned referral form. In the case of CANNOT downloaded forms please sign digitally. 1in4 People Ltd Mental Health Recovery Centre Advocacy Services 39 Oxford Street Weston-super-Mare North Somerset BS23 1TN Phone: 01934 417362 (IMCA/IMHA/DoLS) /622292 (reception) Fax: 628823 Email: advocacyworker@friendcmhrc.com
I confirm that 1in4 People Ltd Advocacy has been instructed by myself to do this work. I agree to 1in4 People Ltd storing my information on a secure database and filing system. I confirm that I understand that 1in4 People Ltd will uphold the Confidentiality Policy and the Data Protection Act with regard to my personal information. ___________________________________ __________________________________ CLIENT SIGNATURE DATE THE REFERRER (leave blank if signed by client) ___________________________________ ________________________________ SIGNATURE DATE ___________________________________ PRINT NAME To ensure that your referral is with promptly ensure that you complete ALL relevant sections and sign before returning. We CANNOT accept an unsigned referral form. In the case of downloaded forms please sign digitally. 1in4 People Ltd Mental Health Recovery Centre Advocacy Services 39 Oxford Street Weston-super-Mare North Somerset BS23 1TN Phone: 01934 417362 (IMCA/IMHA/DoLS) /622292 (reception) Fax: 628823 Email: advocacyworker@friendcmhrc.com
North-Somerset-MCA-DoLS-Local-Practice-Guidelines-Oct-2014.docx