Lena by Inspire Referral Form

Online referral form for Lena's Counselling and/or High Intensity Services

Welcome to the registration page for Lena by Inspire.

Inspire need to gather the information below so that we can register you on our case management system. All our records are held in compliance with EU GDPR/Data Protection Act 2018. Click here to view the Inspire Privacy Policy.

Thank you for taking the time to complete this information.

Online Referral Form - Lena Workplaces Test

Staff Number(Required)

First & Second Name(Required)

Gender(Required)

Date of Birth(Required)

Email Address(Required)

Mobile(Required)

Please prefix with/include your international dialling code ie 44 for Northern Ireland/UK numbers or 353 for Ireland numbers

GP Name & Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Preferred Location(Required)

Please state the nearest town/city to where you wish to be seen. We will endeavour to accommodate your preference however not all services are available in all areas.

Would you prefer to be contacted by phone or email?(Required)

Phone

Are there times / days that suit for follow up?

By checking the relevant box below and submitting this form, you are consenting to Lena keeping a record of your information. This is to enable us to correspond with you to complete the referral process, arrange appointments, and the ongoing delivery of treatment. You can read about how we keep your data protected in our Privacy Policy.(Required)

Yes, I give my consent

Yes, I have consent (if completing on someone’s behalf).

Phone

This field is for validation purposes and should be left unchanged.