Step 1 of 3 33% FacebookThis field is for validation purposes and should be left unchanged.The information you enter into this form will be collected and stored by The Living Room.(Required)Tick the box below to confirm you understand I understand Preferred hubStevenageSt AlbansWatfordSupport required for:AlcoholSubstanceFamily & CarersDisordered eatingOtherOther: please state hereConfidential once completed Client InformationDo they live in Hertfordshire?(Required) Yes No Town(Required)County of Residence(Required)PostcodeName of client(Required)Date of Birth(Required) Day Month Year Email Address Contact NumberAddiction: please provide detailsReasons for ReferralIs the client currently using?(Required) Yes No Family & Carers: please provide detailsBackground and Relevant HistoryBackground and Relevant HistoryMedicationSpecial Access Needs or Disability Professional InformationOrganisation NameName of Professional(Required)RoleEmail Address(Required) Contact NumberCompletion Date Day Month Year Have you obtained consent for this referral from the client?(Required) Yes No Further DetailsThe Living Room trading as ‘The Living Room Hertfordshire’ and ‘Families Living in Recovery’ is a Registered Charity in England and Wales. Registration No. 1080634. CIO Registration 1175541. Registered Office Address 8-10 The Glebe, Stevenage, Hertfordshire, SG2 0DJ. www.livingroomherts.org / Facebook: LivingRoomHerts / Twitter: @livingroomherts / Instagram: @livingroomherts We will always store your personal details securely. We’ll use them to provide the service that you have requested, and communicate with you in the way(s) that you have agreed to. Your data may also be used for analysis purposes, to help us provide the best service possible. For full details see our Privacy Policy. https://www.livingroomherts.org/privacy-policy Your data(Required) I (the client) give consent for my personal data to be handled by The Living Room as explained in the Privacy Policy
