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General Carer Questionnaire
Confidentiality
Read Privacy Statement
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Privacy Statement
All information entered on this form is private and confidential. As a mental health service, we prioritise your privacy and the confidentiality of your personal and health information. The details you provide will only be used to support your care and treatment and will not be shared with any third parties without your explicit consent. Your trust is important to us, and we are committed to protecting your privacy in accordance with applicable privacy laws and professional standards.
You are?
Your Name
*
Post Code
Email
Text/Phone
Your Age?
Referral by?
Self-Referral
Court
Doctor
Employment Support
Solicitor
Ronald Dahl's
Other
Referral by?
Caring For?
Caring For?
Partner
Mum
Dad
Son/Daughter
Sibling
Grandparent
Friend
Other
Other
Approx age?
0-10
11-15
16-25
26-45
47-70
71+
Condition?
Neurological
Physical
Other
Other
Which Condition?
Name of condition
Description of Symptoms
What symptoms?
If you are human, leave this field blank.
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