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C Care Self Referral
Request for C Care services to be provided to an individual/individuals in need
Full Name (First and Family Name)
Contact number (mobile)
Contact number (home)
Date of Birth
I consent for C Care to collect, use and disclose my personal information (including relevant health information) for the purpose of assessing whether they are able to assist me with their service offerings; and in assisting me where relevant
Please provide a brief description of your circumstances (background) and why you require C Care assistance (immediate needs)
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