Referral Form Play Therapy Adult Counselling (Page 2 of 2) in pdf

Referral Form Play Therapy Adult Counselling Page 2

REASON FOR REFERRAL

In which Council Area do you live?

Bristol / South Gloucestershire / Other ___________________

What is your ethnicity? (optional)

(This information helps us with monitoring and funding applications)

I ___________________________________________ (Print Name)

1 Agree to this referral being made to The Bourne Family Project and I have seen its contents.

2 Agree to The Bourne Family Project holding personal information about me on file in

accordance with the data protection act.

3 Give my permission for members of staff from The Bourne Family Project to contact the

agencies that I have indicated above on my behalf.

___________________________________________ (Signature) _______________ (Date)

Thank you for taking the time to complete this form. Please forward it to:

Counselling Administration -

The Bourne Family Project

Bourne Chapel, Waters Road, Kingswood, Bristol BS15 8BE

Tel: 0117 947 8441 Fax: 0117 947 8316 E-mail:

Revised Jun 2013

The Bourne Family Project is part of Bristol Community Church Trust – Registered Charity No: 1044496

Referral Form Play Therapy Adult Counselling Page 2