By completing this form, you are consenting to Choices storing your data. This means that we will store it securely and control who has access to it. At Choices, we recognise that the information you provide may be sensitive and we will respect your confidentiality. We will not share any information where we are not legally required to do so. Your data will be stored securely only for as long as the data is needed for in accordance with the Article 89(1) of the Data Protection Act 2018.

If you have any questions, please email:
info@choicescharity.org

Referral Form

Counselling Service Required *

Please select which counselling service you would like to refer a client to

Referrer First Name *

Referrer Last Name *

Referrer Organisation

Referrer Email *

Referrer Phone

Client First Name *

Client Last Name *

Client Email *

Client Phone *

Client Needs *

What are the client’s needs? (please give any details about the nature of your client's support needs)

Impact on the Client

Do any of the following impact upon why the client needs this support? (select all that apply): - Unplanned pregnancy, mental health challenges, physical health challenges, single parent, low income, domestic abuse, unemployment, homeless, NRPF, relationship breakdown

Unplanned pregnancy

Mental health challenges

Physical health challenges

Single Parent

Low Income

Domestic Abuse

Currently Homeless

Currently Unemployed

Relationship Breakdown

NRPF

Receiving Benefits

Client Ethnicity *

Client Age *

Client Borough *

Client Religion *

Client Disabled *

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The Choices team

Stay in the Loop

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Email Address

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Choices

390 Caledonian Road,
London, N1 1DN

info@choicescharity.org

Choices is a charity that offers counselling for unplanned pregnancy, during pregnancy, following pregnancy loss and for post abortion concerns. We also offer practical and therapeutic help with parenting including our parenting course.

Choices is an independent and confidential counselling service, therefore, you can be sure of impartial support. We will discuss all your options with you and support you whatever decision you reach. We are an organisational member of the British Association for Counselling & Psychotherapy (BACP). Registered charity no. 1124209

Read our Policies: Safeguarding Adults at Risk Safeguarding Children Privacy Complaints