REFER A CLIENT

 

This contact form is for health or other practitioners who would like to refer a client/patient to Freedom from Food for treatment. Please fill out the form with the relevant details and if you have any questions, please do not hesitate to reach out via email at bianca@freedomfromfood.com.au or by phone on 0422014782.

Your Name*:
Your Email*:
Your Phone*:
Profession*:
Name of business:
Client/patients' name*:
Client/patients' phone number*:
Client/patients' email address:
Brief description of your client/patient and why you are referring*:
Do you want me to get in contact with the client/patient or would you prefer for me to wait for them to reach out?*:
Would you like to discuss this client/patient over the phone before their first appointment?*:
Would you like me to follow up with you after the client has had their first appointment?*:
Is there anything else you would like me to know?:
Please attach any relevant files:

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Data Collection, Processing, and Privacy Statement

Thank you for entrusting Freedom from Food with your personal information. Please be assured that the information collected in this form is treated as confidential and will strictly only be used for the intended purpose of engaging with therapy. This information will never be sold or passed on to third parties. Personal information entered into this form will not be stored on the website but, in a secure location that only Freedom from Food will have access to. Completion of this form implies consent for Freedom from Food to use this information for the purposes of therapy and securely store your data. Information obtained during the course of therapy is required by law to be kept for seven years, after which point, records will be destroyed.

Follow Freedom from Food on Instagram @thehaeshypnotherapist

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I would like to acknowledge the Wurundjeri people who are the Traditional Custodians of this land upon which Freedom from Food operates. I would also like to pay respect to the Elders both past and present of the Kulin Nation and extend that respect to other Indigenous Australians, past, and present.


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