Pragmatic Tracker Client Referral

Date of Birth

Please use dd/mm/yyyy format or click the calendar button to select your date of birth.

Gender

Please select from the list.

You may choose 'not given' or 'prefer not to say' if you wish but knowing this could help us to help you.

Employment

Please select from the list the option that best describes your current employment status.

Living Arrangements

Please select from the list the option that best describes your current living arrangements.

Dependents

Please enter the number of others who are financially dependent on you, eg. number of children under 18 living at home.

Ethnicity

Please select from the list the option that best describes your ethnic background.

Medication

If you're currently on medication please select the type(s) of medication you're taking. You can select more than one type by holding down the [Ctrl] or [Cmd] key while selecting the second and subsequent types.

If you select a medication type here another box will open for you to enter the exact drugs you're taking.

GP Name & Address

Please enter the name of your GP and their contact address.

If you don't know your GP's name then the name and address of the practice or surgery will suffice.

GP Phone Number

Please enter a contact telephone number for your GP or GP practice.

GP contact

Do we have your permission to contact your GP?

GP correspondence

Do you wish to see a copy of any correspondence with your GP.

GP email address

Please provide the GP email address if you know it.

I.C.E (in case of emergency)

Who should we contact in the event of an emergency?

I.C.E (in case of emergency) phone number

Please provide a phone number for your emergency contact.

Relationship to your emergency contact (I.C.E)

What is your relationship to your emergency contact (e.g. friend, family member)?

Additional needs

If the answer is 'yes' please let us know what they are.

Prior attendance at HLC

If you have attended HLC before please provide some details.

Personal links to HLC

If you have personal links to HLC please provide details.

Your Address

Please enter your address

Your Eircode

Please enter your eircode

Therapy type

Please select the type of therapy your are requesting

REFERRAL FORM