Make A Referral Directly To Service Six

This form is for self-referrals & assisted self-referrals to access Service Six’ services. An assisted self-referral is when you have someone who is helping you to complete this form.

The information provided will be used to enable us to offer the most appropriate services and actions will be kept confidential and securely stored and shared as appropriate within Service Six. Confidentiality is central to our work but it is not absolute - there are legitimate exceptions of some circumstances which require Service Six to share information with others, such as; if a person is at risk of serious harm by others; if a person is at risk of serious harm to them self or to others; or there is a risk of serious crime. A copy of our Confidentiality & Data Protection Policy is available on request or can be found here.

 

Some information will be used for reporting purposes; in these cases the data will contain no identifying information that could associate you with receiving a service. Any other information will not be released without your consent unless required by law or a court order as stated above.

 

We are not able to offer you counselling/therapy if you are seeing another counsellor or psychological therapist, or if you are currently receiving a high level of Mental Health Care. In those cases we might be able to offer you any other support services which is not counselling.

 

Prior, during or after you receiving a service you can contact Service Six at 01933 277520 or send an email to

referrals@servicesix.co.uk for any questions you might have.

Please complete the form as fully and accurate as you can.

* required

If form does not submit check that you have completed all the required fields

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Submitting Form...

The server encountered an error.

Form received.

 

 

 

E: info@servicesix.co.uk

T:  01933 277520 / 01933 273746

 

General Data Protection

Your privacy is important to Service Six and we take our responsibility regarding the security of your personal information very seriously.

Service Six is committed to protecting your personal information and to being transparent about the information we are collecting about you and what we do with it.

To reflect the newest changes in Data Protection Law, and our commitment to transparency, we have updated our Privacy Policy.

We understand that making a referral to Service Six or enter an employment or similar arrangement with Service Six involves a great deal of trust on your part and this trust is very important to us.

If you would like to find out more, take a look at our Privacy Policies.

Privacy & Cookies

Policies

All Rights Reserved

Copyright © 2017 - Service Six

Registered Charity Number: 1132490 Company Number: 06740611

Submitting Form...

The server encountered an error.

Form received.

Supporting Children, Young People, Adults, Families & Communities

a