Referral Form

Please note: You must attend an initial assessment before commencing any course. If you do not attend this assessment, and we receive no contact, we will assume you no longer require the course

Personal Details
Emergency contact
Referred for and Why?
Services
Problems or needs
Associated Risk Factors
Other Support
Preferred language

Please note: We will try to accommodate your language preference. However, if this is not possible, the course will be conducted in English.

Referrers Details

Regarding other organisations: It is the responsibility of the referrer to get consent to make this referral. Ponthafren may need to speak to the referrer for further relevant referral details, regarding waiting times, or to notify of client non-attendance. If there is no consent for this, you are welcome to make this a self-referral and to not provide referrer contact details below.

For further information on how your referral relates to GDPR, please visit out referral privacy notice:
www.ponthafren.org.uk/privacy-notice-referral-form/