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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
Professional referral form
If you are a professional referring a family, please complete the following referral form:
Child's Forename and Surname:
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 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 address:
City:
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
Post Code:
Name and title of parent or carer:
Contact Number:
Email address:
Preferred method of contact:
Email
Phone
Childs NHS Number:
Child's GP Surgery:
GP's Address:
Post code:
Parental Responsibility:
Yes
No
Interpreter required:
Yes
No
Language Spoken:
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
How did you hear about GEMS?
Other Professional Involvement:
Name of referrer:
Service/Job title:
Referrer's email address:
Contact telephone number:
Has the referral been discussed with the parent/carer and have they provided consent for their information to be shared with GEMS?”
Yes
No
Has the parent/carer provided consent for GEMS to store information on our database?
Yes
No
Is service user happy to complete a survey?
Yes
No
Please provide a detailed description of the current difficulties the family are experiencing with their child's behaviour at home and at school in relation to Autism and or ADHD? i.e. sleep, sensory processing, anger, friendships, meltdowns etc.
Who lives with the child at their home? i.e. mum, dad, siblings, grandparents etc.
Does the child have any other conditions or diagnosis that may impact their behaviour and or needs?
Does the parent/carer have any access need /neurodivergence relevant for this referral?
Has the family accessed any training or resources in relation to Autism and ADHD previously?
Have the family accessed any general parenting workshops or courses previously? Such as Triple P, Solihull approach, Positive Parenting Support (PBS)
What support have school put in place for the child, if relevant?
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
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