Help Someone you know

Referrer Information

Referrer's Full Name (required)

Referrer's relationship to the person being referred (required)

Referrer's email (required)

Referrer's Telephone Number (required)

Information of person being referred

First Name (required)

Last Name (required)

Address Line 1 (required)

Address Line 2

City (required)

Postal Code (required)

Date of Birth. Enter YYYY-MM-DD (required)

Ethnicity: (required)
—Please choose an option—WhiteWhite BritishWhite IrishWhite Gypsy or Irish TravellerWhite EuropeanOther WhiteMixed/Multiple ethnic groupsWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed/Multiple ethnic backgroundAsian/Asian BritishIndian / British IndianPakistani/Pakistani BritishBangladeshi/BritishChinese/BritishAny other Asian backgroundAfrican/Caribbean/Black BritishBlack BritishAfricanCaribbeanAny other Black/African/Caribbean backgroundArabAny other ethnic groupPrefer not to say

Preferred telephone number to contact you (required)

Your Email (required)

We are not in a position to offer counselling in a different language at the moment, but if in the future the opportunity does arise, would they prefer a different language?
—Please choose an option—yesno

if yes, what would be their preferred language?

Contact Permissions

Allow direct email (required)
—Please choose an option—YesNoUnknown

Allow bulk email/newsletter (required)
—Please choose an option—YesNoUnknown

Allow post (required)
—Please choose an option—YesNoUnknown

OK to contact by phone (required)
—Please choose an option—YesNoUnknown

OK to contact on mobile phone (required)
—Please choose an option—YesNoUnknown

Allow texts (required)
—Please choose an option—YesNoUnknown

Additional comments on contact permissions

I received the consent of the person being referred to contact Quetzal on their behalf and I also give consent to Quetzal to store my contact information.