I confirm that verbal consent has been given for me to make a referral on this person’s behalf. They’re aware that the information given on this form, and any future contact with +Choices will be used to provide them with support and will be kept confidential. The information given may also be used for monitoring purposes within the +Choices service and its partners. Been made aware of the +Choices programme by the referrer. Have recognised and accepted that their behaviour is abusive. Be willing to engage in a programme designed to change their behaviour.

I give consent to +Choices and its employees to contact me. I understand that the information I give on this form, and any future contact with +Choices, will be kept confidential. I understand that the information given may also be used for monitoring purposes within the +Choices service and its partners.