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| Referral Application | |
| Referral Record - Confidential | |
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The simplest and most reliable way of ensuring your referral reaches us in confidence is as follows:- Complete the form online. Go to 'Edit' at the top of your browser > 'Select All' > right click and 'Copy'. Left click on this page (to clear the highlight) >click on our email address here - remapleeds@aol.com - or on the 'Contacts' page and 'Paste' into the body of the message. Alternatively, this referral form can be completed online and printed to be sent by post to the address on the Contacts page. It may also be printed with blank entries for photocopying or completion by hand if preferred. |
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| Return to Referrals page - (Note! Returning clears entries in the boxes below) |
| Client Information | |
| Name | Date |
| Address | Male Female |
| Age Group: 0-18 19-65 66+ | |
| Postcode | |
| (Postcodes are especially useful to assist client location) | |
| Tel: Mobile: Email: | |
| Referrer (The 'Referrer' can be a private individual) | |
| Name | |
| Address | |
| Postcode | |
| Tel: Mobile: Email: | |
| Description of Problem | |
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Return to Referrals page - (Note! -Returning clears entries above) |
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