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City of Glasgow College Referral
"
*
" indicates required fields
1
About You
2
Contacts
3
Session
4
Referrer
5
Submit
Referral Reason
*
Book a BYOB Session
Clinical Supervision
Referral Type
*
Self Referral
Referring on behalf of someone else
Please fill in all fields with the referred's details - you will have an opportunity to fill in your details before submitting.
Name
*
First
Last
Phone
*
Email
*
How Do You Identify?
*
Man
Woman
Genderqueer/Non-binary
Other
Prefer not to disclose
Date of Brith
*
DD slash MM slash YYYY
Address
*
Street Address
Address Line 2
City
Post Code
Your GP
GP Name
*
GP Address
*
Street Address
Address Line 2
City
Post Code
Your Emergency Contact
Emergency Contact Name
*
First
Last
Emergency Contact Phone
*
Your Relationship to the Emergency Contact
*
When would be a good time for your online sessions?
*
Monday Morning
Tuesday Morning
Thursday Morning
Wednesday Morning
Friday Morning
Monday Afternoon
Tuesday Afternoon
Wednesday Afternoon
Thursday Afternoon
Friday Afternoon
Monday Evening
Tuesday Evening
Wednesday Evening
Thursday Evening
Friday Evening
Select as many as you wish
What is your relationship to the referred?
*
Lecturer
Line Manager
HR
Other
Referrer Name
*
First
Last
Consent of the Referred
*
I confirm that I have the consent of the referred to submit a referral on their behalf
Is there anything you would like to add?
Personal Data Consent
*
I confirm that I have read and understood how the personal data submitted in this form is handled and retained
The Talking Rooms' Privacy Policy
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Comments
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In Crisis?
Need Help?
0141 459 0011
info@thetalkingrooms.com
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