Family Connections Referral Form

The personal details you supply in the below form will be used to administer your application and attendance on the Family ConnectionTM course run by Humber Teaching NHS Foundation Trust. Under the UK General Data Protection Regulation our lawful basis for processing this information is your consent.  You are able to withdraw your consent at any time by contacting

The information in this form will be sent to us encrypted.  We will then store this information securely at the Trust for a period of 12 weeks following completion of the course.  After this, your personal information will be deleted. Your relationship to your supportee, and the age bracket within which you and they fall, will be retained for statistical purposes and may be presented as part of anonymous pooled data to internal and external stakeholders when reporting on the Family Connections programme. This will never be identifiable and will be combined with other anonymous data.

If you have any concerns about our use of your personal information or if you wish to exercise your data protection rights please contact

By submitting the form, you consent to your personal data being used as outlined in the above privacy information.

Please complete the form below if you would like to self-refer to attend the Family ConnectionsTM programme at Humber Teaching NHS Foundation Trust. Please note, this information relates to the person wanting to attend only.

Please confirm that you or the person you support with emotion dysregulation are registered with a GP in the Hull or East Riding Clinical Commissioning Group areas.*
Having reviewed the list of typical difficulties experienced by people with emotion dysregulation in the Humber FC leaflet, do you believe that the person you support experiences difficulties such as these?*
What is your relationship with the person with emotion dysregulation?*

Due to the ongoing social distancing restrictions in NHS buildings, all Humber Family Connections courses are currently being delivered online via Microsoft Teams.