Self Referral Form

Please complete and send this form if you would like therapy for yourself.

All information will be treated as confidential.

* indicates required fields

Your details

First Name: * Family Name:* Date of birth: Day/Month/Year Gender: Address Line 1:* Address Line 2: Address Line 3: PostCode:* Telephone Number:* Email Address:* What is the best time and way to contact you? Please tell us briefly why you are looking for trauma focused therapy? * Please tell us about any special needs you may have?

Other Information

I confirm that:

I am resident in Oxfordshire.
I am looking for therapy because my life is seriously affected now by difficult experiences in the past.
I have ongoing support available (if needed) for such issues as benefit claims, housing, court cases or immigration status.
I am not actively suicidal.
I am unable to pay the usual fees for private therapy or access appropriate trauma therapy through the NHS or insurance.
I consent to MEET using my personal data in accordance with General Data Protection Register 2018 (GDPR) as outlined below.

We keep computer and hard copy records in order to follow the progress of clients’ therapy.
We use strong passwords on computers and keep written records in a locked filing cabinet.
We will not disclose or provide client details to a third party without their written permission.
We may compile anonymous statistical data from time to time.
We keep client records for a period of seven years after therapy finishes in accordance with the requirements of our insurers.
Please email us if you would like access to your data or have any concerns about the use of your personal data

I agree with the above and confirm that I would like to have an assessment for trauma focused therapy from MEET in Oxford

Please give the name and contact details of your GP. We would like your permission to make contact to check that the service MEET in Oxford offers is right for you.

Name, surgery and address of your GP *
I give permission for MEET in Oxford to correspond with my GP in relation to my request for trauma focused therapy.

Please tell us about any other professional or service you have been working with. Tick the box below if you are happy to give permission for us to contact them if we feel this would be helpful.

Name and contact details - 1 Name and contact details - 2
I give permission for MEET in Oxford to correspond with the individual/s or service/s named above in relation to my request for trauma focused therapy.

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