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.
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.