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Home
About Services
Open menu
About us
About ADHD
About Autism
Animations
Forms
Open menu
Professional referral form
Parent submission form
Feedback form
Family Support
Open menu
Social groups
Workshops
Contact Us
Open menu
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
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:
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:
Current Pathway:
ADHD
Autism
Both
Pathway stage:
Diagnosed
On waiting list
Suspected
How did you hear about GEMS?
Other Professional Involvement:
Name of referrer:
Service/Job title:
Referrer's email address:
Contact telephone number:
Referral discussed with the parent/carer/service user
Yes
No
Service users consent obtained to share information
Yes
No
Service users consent obtained for GEMS to store information on their database
Yes
No
Is service user happy to complete a survey?
Yes
No
Reason for referral:
Expected outcomes of referral:
General Consent:
Please confirm your service user agrees to their information being used as described below: 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).
Submit
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