01483 454 433   referral@headwaysurrey.org    counselling donate contact us

referral form

referral form

If you are completing this form for somebody else, please enter their details in section 1 and your own details in section 2.

Section 1 - Person being referred

Name
example: 10/12/1969
Address

Section 2 - Person making the referral

Name
Which is the best way to get in touch?

Brain Injury Details

e.g. Hospital discharge letter
Please indicate if you would like immediate contact or a preferred date from when you would like to receive contact from Headway Surrey
Any other relevant information you would like Headway Surrey to know prior to contact being made
How did you hear about Headway Surrey?

Confidentiality declaration

As part of Headway Surrey’s duty of care, we keep this information to allow Headway Surrey staff to provide appropriate care in the event of an emergency. Personal information gathered by Headway Surrey is kept in confidence in accordance with the Data Protection Act of 1998 and the GDPR Law of 23rd May 2018, and will only be disclosed to relevant medical staff with the client’s permission or if the client is unable to give consent. Headway Surrey has a responsibility to protect the privacy of those using its services and attending its centre.