01753 373 244 | 0800 999 1342 (Mon-Fri 9am-5pm)
gems.4health@nhs.net
Facebook-f
Twitter
Instagram
Home
About Services
About us
About ADHD
About Autism
Animations
Forms
Professional referral form
Parent submission form
Family Support
Social groups
Workshops
GEMs Advice
Contact Us
Subscribe
Home
About Services
About us
About ADHD
About Autism
Animations
Forms
Professional referral form
Parent submission form
Family Support
Social groups
Workshops
GEMs Advice
Contact Us
Subscribe
Parent submission form
Child's details:
Child's Forename and Surname:
Child's DOB:
Child's Ethnicity:
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Asian or Asian British - Indian
Asian or Asian British - Japanese
Asian or Asian British - Pakistani
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Other Black Background
Do not wish to disclose ethnic group
Mixed - Other Mixed Background
Mixed - White Asian
Mixed - White Black African
Mixed - White Black Caribbean
Other ethnic group
White - British
White - European
White - Irish
White - Other White Background
Child's gender:
Male
Female
Gender Same at Birth
Yes – same as birth
No – Not same as birth
Do not wish to disclose
Child's address:
Accommodation Type
Owner occupier
Tenant – Private landlord
Tenant – Local Authority/ Social Housing
Living with family
Living with friends
University or College Accommodation
Accommodation tied to job (I.e. armed forces)
Admitted Patient setting
Specialist Housing (with suitable adaptions to meet impartments or to live independently)
Other not Listed
Do not wish to disclose
City
Post Code
Autism Pathway
Yes
No
Autism Stage
Yes my child has a diagnosis
No – My child is waiting for an assessment
No – I think my child may be autistic
No
ADHD Pathway
Yes
No
ADHD Stage
Yes my child has a diagnosis
No – My child is waiting for an assessment
No – I think my child may be autistic
No
If child has a diagnosis of ADHD, do they receive medication for their ADHD?
Yes
No
Child's details:
Parent's name:
Contact Number:
Email address:
Preferred method of contact:
Email
Phone
Language Spoken:
Interpreter required:
Yes
No
Parental Responsibility:
Yes
No
Child's GP details:
GP Surgery:
GP Address:
Post code:
GP Phone number:
Childs NHS Number:
Any social care involvement?
Yes
No
How did you hear about GEMS?
Are you happy to be sent a Survey?
Yes
No
What is the main reason you are contacting us?
Is there anything else you wish to share with us regarding your child's behaviour at home or at school in relation to Autism and or ADHD?
Does your child have any other conditions or diagnosis that may impact their behaviour and or needs?
Do you have any access needs/neurodivergence relevant for this referral?
What support have you accessed prior to this request: - i.e. any workshops/other agency involvement such as OT, SALT, Early Help, Social services etc.
What have strategies have you tried previously? Please advise what strategies have worked and what didn’t?
Subscribe with us to get latest updates and information
General Consent:
GEMS as part of Solutions4Health request consent for your personal information to be stored and also to be shared with our workshop delivery facilitators who require this in order to send you information related to the workshop. We also use non-identifiable information for reporting purposes. If at any point, there are concerns relating to safeguarding we are obliged to share relevant information. You can also remove your consent for us to store and share data at any time by writing in to gems4health@nhs.net
Submit
Select language »
