WHM Easy Read Self-Referral Form Logo
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  • Easy Read Self-Referral Form

  • Please complete as much of this form as possible.

  • Please have a look at the 'Our Services' page on our website to find out about our projects: https://www.womenshealthmatters.org.uk/services.

  • About Me

    About Me

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  • *withheld means you cannot see the number of the person calling.

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  • Women's Health Matters will save and use the information on this form to process your referral. 

    Your details will be kept in our secure and safe database. Your information will not be shared with anyone else without your permission.

     

    We need to save your infomation so we have your contact details, such as your phone number. This will allow us to contact you.

    This means we will be able to get in touch with you:

    - To explain more about the project.

    - To tell you when and where group will be.

    - To tell you if group is ever cancelled.

    - Or if we needed to contact you in an emergency. 

     

    Please tick below to say that you agree for us to save your infomation in our safe and secure database.

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