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About Services
Open menu
About us
About ADHD
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Professional referral form
Parent submission form
Feedback form
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Contact Us
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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
Child's address:
City
Post Code
Current Pathway
ADHD
Autism
Both
Pathway Stage
Diagnosed
On waiting list
Suspected
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
Reason for referral: Please provide as much information as possible about your current situation and what support you are interested in accessing from GEMS to support your family
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General Consent:
Solutions 4 Health would encourage you to provide your consent in order that we can process data and information about you. We will share this data where necessary with other health professionals such as your GP or specialist services. The information we collect and process will be used to help us meet the contractual obligations as set down by the local health service commissioners in accordance with the service we are providing. You can request to view, amend or delete your data at any time by contacting us at (www.Solutions4Health.co.uk/contact).
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