Referral form - Gems4health

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:

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

Pathway stage

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.