Veterans At Ease Referral Form

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Veterans At Ease Referral Form

We are dedicated to providing the best possible therapeutic support to veterans, their families and members of the emergency services. To best do this, we need some information from you. This information is stored securely and confidentially.

Please answer as best as you can, giving as much detail as you feel appropriate. The only required answers are your name, contact information and permission for us to use them - if you do not wish to put your reasons for accessing our services on this form, we can call you and discuss them.

Email *

What is your full name? *

What is your preferred name? (Nickname etc.)

What is your address? Please include your postcode

What is your email address? *

What is the best contact phone number for you? *

Do you give consent for us to contact you via the below methods: *

Phone and email

Phone only

Email only

What branch of the military did you serve in?

Navy

Army

Air Force

Merchant Navy

Blue light emergency services

Immediate family member of someone who served

Non-military connected (paid for sessions)

Clear selection

What brings you to Veterans at Ease? Why us and why now?

Do you have an existing mental health diagnosis?

Yes

Clear selection

If yes, please provide brief details.

Do you have a physical disability that we need to know about?

What is your preferred format of therapy?

Face to face

Online

Telephone

No preference

Clear selection

Is there anything else that you want to tell us?

Send me a copy of my responses.

Submit

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