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gems.4health@nhs.net
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Menu
Home
About Services
Open menu
About us
About ADHD
About Autism
Animations
Forms
Open menu
Referral form
Parent submission form
Feedback form
Family Support
Open menu
Social groups
Workshops
Contact Us
Service referral form
If you are a professional referring a family, please complete the following referral form:
Full Name and title of parent or carer:
Full Name of child:
Child's gender:
Male
Female
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
Address Line 1
City
Post Code
Contact Number:
Email address
Preferred method of contact:
Email
Phone
Childs NHS Number
Child's GP Surgery
GP's Address
Post code
City
Parental Responsibility:
Yes
No
Interpreter required
Yes
No
Language Spoken
Current Pathway
ADHD
Autism
Both
Pathway stage
Diagnosed
On waiting list
How did you hear about GEMS?
Other Professional Involvement
Name of referrer:
Referrer's email address:
Agency/Position
Contact telephone number
Reason for Referral:
Consent:
Under the General Data Protection Regulation (GDPR) (EU) 2016/679, we have a legal duty to protect any information we collect from you. Information contained in this form may be privileged or confidential and intended for the exclusive use of providing support to you through the GEMS service. Details provided will be stored on our database and so that services can be delivered by our partners, Parenting Special Children and The Autism Group, this information will be shared with them. Information stored on our database will be used for reporting purposes to our funders, NHS East Berkshire CCG. ( ) I consent to information submitted being used as detailed above.
Submit
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