Referral Form Please fill in the form below. Our friendly family support team work Wednesday – Saturday so once you have submitted we will be in touch within 5 working days to discuss any further information and next steps. I am a Parent ProfessionalSeeking: Support for a complexly poorly child Support for child lossI'm making this referral for: Myself On behalf of someone elseFirst Name Last Name Email Subject Your Message The personal information you provide will be kept secure and only used by Reuben’s Retreat personnel to support the delivery of our charitable activities. Reuben’s Retreat may be required to share some of the non-identifying information where relevant and appropriate to the bodies responsible for regulating and/or funding Reuben’s Retreat. You can ask for your personal information to be removed from our records at any time however there are limitations on this, such as where we must retain the data for legal or regulatory purposes.Consent to Receive: Explicit consent to capture, store and use dataEmailTelephone/leave messageSMSCorrespondenceSubmit Form I am a: I am a: Parent Professional Seeking: Seeking: Support for a complexly poorly child Support for child loss I'm making this referral for: I'm making this referral for: Myself On behalf of someone else Full Name Email Address Phone Number If you are a professional making a referral on behalf of somebody else, please add more details below: How did you find out about Reuben's Retreat? How did you find out about Reuben's Retreat? Google/ Internet Search Social Media From a magazine or publication From a Doctor From a health worker or professional Other Submit