Referral Creation Wizard

Complete the following referral form to submit a request for service to LINC .

Client

Personal Information

Enter the client's forename.
Enter the client's surname.
Enter a contact number for the user.
Enter the client's email address.

 

Please enter the client's date of birth (format: dd/MM/yyyy)
Please select the clients gender.

Address Information

Enter a street and house number.
Optionally enter a town.
Optionally select a county.
Optionally select a country.
Enter the postcode area
Enter a postcode

Preferences

Please select a service.
Please select a referral source from the list below.

Issues

Please give brief details about the situation for which counselling is being requested (including any medical / family history).
Please select a how did you hear about us option
Please tick if you have used this service before?
If you have used the service before, please give us some details on this.
Please explain what you hope to achieve from counselling, e.g. do you have any goals in mind?

My Issues *

Select one or more of the issues you are experiencing.

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General Practitioner (GP)

General Practitioner Details

Please select an existing GP from the list below.
If your general practitioner doesn't exist in the list above tick this checkbox and complete the new GP form.

Emergency Contact

Emergency Contact Details

What is the name of the emergency contact?
Please supply a contact number
Please state the relationship to the emergency contact

Consents

Our responsibilities

We hold and store data that you share with us. This data can include your name, date of birth, address and information relating to your health and wellbeing. We use this information to make sure that your care or treatment is appropriate for you. All data is stored securely and only accessed by LINC employees involved with your care. We keep your data for the time identified by the 'Records Management Code of Practice for Health and Social Care', by the Information Governance Alliance (2016). 


On occasion, it may be necessary to share your data with other agencies. These agencies may include States of Jersey departments, your GP practice or other healthcare professionals involved in your care. We will ask you prior to making any referrals. However, there are some circumstances in which we are required to share your details. These include: 

  • If there are significant concerns that you intend to harm yourself or others
  • If we are instructed by a court to disclose information
  • If it is necessary in order to uphold child protection laws

We will not share your information with third parties for marketing purposes. We may contact you to let you know about other services, events or for evaluation purposes. 

Your responsibility

We would ask that you keep us informed (by email, telephone, or in writing) of any changes in your personal data so that we may have our records up to date at all times. If you wish to withdraw your consent please contact us (by email, telephone, or in writing). You have the ‘right to be forgotten’, which means you can request the deletion or removal of personal data where there is no compelling reason for its continued processing.


Access permission

I consent that you can share details with my GP and other 3ʳᵈ parties who are involved in the contract entered into by you and us

Communication Permission

I consent that I'd like to hear from you via email

I consent that I'd like to receive SMS texts from you

I consent that I'd like to receive letters from you

I consent that I'd like to receive phone calls from you

I consent that I'd like to receive voices messages from you

I consent for my emergency contact to be contacted if necessary

Leave unchecked and we will not contact you via this method

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