SELF-REFERRAL FORM

Please provide as much detail as possible on this form to help us decide if you can be supported by Checkin/Giraffe; it helps us assess whether the programme is appropriate for your needs, and allows us to adjust our support to be as relevant as possible for you.

    Your Details:

    Referral Agency Details

    Please complete this section if you have been referred to CheckIn/Giraffe by another agency or support person.

    Reason for referral

    Do you have a condition/disability which is covered by the Equalities Act?:

    YesNo

    Additional information

    Consent

    I understand that the information that I am providing is being collected under the Data Protection Act 1998.
    It will form part of the individual’s file and if the individual requests to see information that Checkin/Giraffe holds on them, under the Act, we would release this information. By submitting this form, you are agreeing to the terms of The Checkin-Giraffe terms of conditions and privacy notice.