Empowered To Thrive CIC | Workshops, Retreats, Events & Community

PROFESSIONAL REFERRAL FORM

To be completed by professional organisations only please.

Referring Organisation Details:

Organisation Name

Referrer's Full Name

Job Title / Role

Professional Email Address

Phone Number

Organisation Address

Reason for Referral (brief summary)

Person Being Referred:

Full Name

Preferred Name (if Different)

Date Of Birth

Contact Number

Client Email

Address

Is the individual aware of and consenting to this referral?

Yes

(Referrals cannot be processed without consent)

Support Needs & Background (tick all that apply):

Brief description of current challenges and support needs:

Risk & Safety Information

⚠️ This section helps us assess suitability and safeguarding needs.

Are there any current safeguarding concerns?

Yes

Is the individual currently at risk of suicide or self-harm?

Yes

Is the individual receiving support from statutory services (e.g. GP, CMHT, crisis team)?

Yes

Additional Relevant Information:

Important:

Empowered To Thrive CIC does not provide crisis intervention. If there is immediate risk, please follow your organisation’s safeguarding procedures and contact emergency services.

Relevant Services Requested:

Long answer

Additional Information (Optional):

Long answer

Referrer Declaration & GDPR:

Consent Statement (Required)

I confirm that the individual named above has been informed of this referral and has given explicit consent for their personal data to be shared with Empowered To Thrive CIC for the purpose of accessing wellbeing and mental health support.

I confirm that the information provided is accurate to the best of my knowledge and shared in line with my organisation’s data protection and safeguarding policies.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Data Protection & Privacy Notice:

Empowered To Thrive CIC is committed to protecting personal data in line with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018.

We will:

Only collect information necessary to assess and provide appropriate support.
Store data securely and restrict access to authorised personnel only.
Never share personal data without lawful reason or consent.
Retain data only for as long as necessary for service provision and safeguarding.

Individuals have the right to access, correct, or request deletion of their data where appropriate.

For full details, please see our Policies or contact: 📧 connect@empoweredtothrive.co.uk

Thank you for your referral.