Please note: due to Data Protection Policy and Client Confidentiality, RTC does not accept any query or referral regarding current or prospective clients electronically. Any email received with such content will be immediately deleted from our system, in line with our policy, without reply. In the best interest of clients, please make all communication in writing and post it to our office and include all the related documents with your covering letter on letter-headed paper. CLIENT PERSONAL DETAILS ‘S Date of referral: Title Surname Forename Marital Status Date of Gender Address: Post Code: Contact Telephone Home Mobile number Languages Spoken Country of Origin Immigration Status Details of next of kin (if client referred is a minor) GP Practice Referrer Details (if different from GP Details) Practice Name: Name of organisation: Contact Doctor: Name of referrer: Address: Address: Post Code: Post Code: Telephone: Telephone: REFERRAL DETAILS Please provide as much relevant detail as possible by attaching additional information on separate, typed A4 paper. Reasons for referral Please continue in a separate page to provide as much information as you can. Details of history and any other mental health interventions (if applicable):
Please note: due to Data Protection Policy and Client Confidentiality, RTC does not accept any query or referral regarding current or prospective clients electronically. Any email received with such content will be immediately deleted from our system, in line with our policy, without reply. In the best interest of clients, please make all communication in writing and post it to our office and include all the related documents with your covering letter on letter-headed paper. CLIENT ‘S PERSONAL DETAILS Date of referral: Title Surname Forename Date of Gender Marital Status Address: Post Code: Contact Telephone number Home Mobile Languages Spoken Country of Origin Immigration Status Details of next of kin (if client referred is a minor) GP Practice Referrer Details (if different from GP Details) Practice Name: Contact Doctor: Address: Post Code: Telephone: Name of organisation: Name of referrer: Address: Post Code: Telephone: REFERRAL DETAILS Please provide as much relevant detail as possible by attaching additional information on separate, typed A4 paper. Reasons for referral Please continue in a separate page to provide as much information as you can. Details of history and any other mental health interventions (if applicable):
Client+Referral+form+3-17.docx