Crisis Response Request

Immediate Psychological Support – Globally

Human Indemnity Following Critical Incidents

Referral Profile

MBL Global Ltd – MBL Now

Note: Both sections 1 and 2 of this document are to be completed by you. All questions with * must be answered.

Section 1: is to record the details of the person referring the matter in the event MBL requires further information.

Section 2: is to provide MBL with contact information for those affected.

No work will be undertaken until terms of service are agreed.

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

1. REFERRER DETAILS

Your Name*

First Last

Your Email Address*

Your Phone Number*

Including local or international dialling codes.

Your Company Name*

Your Position*

Do you have an MBL emergency reference number?*

Yes

This will have been provided to you in your insurance policy documentation or by your Broker or Crisis Response partner.

If yes, please provide your MBL emergency reference number below

Details of Insurance Policy or Crisis Responder who may insure / attend the event

If known.

2. DETAILS OF PERSONS REQUIRING COUNSELLING and NATURE OF INCIDENT

If not yourself, the name and contact details of the person we are to make first contact with. This should be the name of the individual to be counselled, or in the case of a family, group or work associates, the name and contact details of the person best prepared to assist with initial communications.

Name*

First Last

Email Address*

Phone Number*

Including local or international dialling codes.

Designation*

Number of people seeking assistance*

Please indicate the (approximate) number of people below.

Please enter a number greater than or equal to 1.

Details of people seeking assistance*

Please include the following details for each person: Name, Surname, Email Address, Phone Number (including local or international dialling codes) and preferred language of engagement if not English.

Have those requiring assistance been advised of our potential engagement?*

Yes

Preferred initial method of contact*

Telephone

Brief details of the incident leading to this request*

Crisis Response Request

Immediate Psychological Support – Globally

Human Indemnity Following Critical Incidents

Referral Profile

MBL Global Ltd – MBL Now

1. REFERRER DETAILS

2. DETAILS OF PERSONS REQUIRING COUNSELLING and NATURE OF INCIDENT

Trust Centre

Emergency Contact

Get In Touch

London

Johannesburg

Are you in an emergency situation?

Emergency Contact