Self or Agency Referral
Welcome to the Connect Gwent Self Referral Form
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By submitting this form on the behalf of someone else, you are confirming that you have had consent from the person that the referral is for. 

On submission of this form, you are consenting to be contacted and any information you provide will be used to contact you and offer support to you. Any information will be treated confidentially and not shared outside of Connect Gwent agencies unless required to do so by law and for safeguarding purposes. 

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What is the reason for your referral today?
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