Referral form - Gems4health

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:

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:

Pathway stage:

How did you hear about GEMS?

Other Professional Involvement:

Name of referrer:

Service/Job title:

Referrer's email address:

Contact telephone number:

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).