Skip to content
Referral By Mental Health Service NHS
Details
Referral for?
*
NHS Funding
Client Will Self-Pay
PIP Referral
Other
Referral for?
What Country?
*
England
Wales
Scotland
Ireland
Other
Note
DisabilityPlus do not currently have the option to support someone in Scotland or Ireland. If a person wishes we can offer self-paid sessions. Self-Paid Sessions are: Session 1 = £50, Every 3 Sessions Thereafter £180
Referral by?
*
Audiologist
Doctor
NHS, Talking Therapies, England
NHS, Talking Therapies, Wales
New Option
NHS, Community Mental Health – Wales or England Team
Rehabilitation (Limb)
Rehabilitation (SCI)
Social Care
Social Sevices
Other
PIP Referral
Disability
*
ADHD
Autism
Brittle Bones
Cerebral Palsy
Epilepsy
Limb Loss
Hearing Loss
MS
Medical (Stroke etc)
Rare Genetic Disorders
Spina Bifida
Sight Loss
Muscular Dystrophy
Spinal Cord Injury
Tinnitus
Vestibular Disorder
Other (put into description)
Not Available
DisabilityPlus do not currently have the option to support someone with this Disability. If a person wishes we can offer self-paid sessions. Self-Paid Sessions are: Session 1 = £50, Every 3 Sessions Thereafter £180
Cause
*
Life long disability
Failed operation
Stroke
Personal injury
Road traffic accident (driver)
Road traffic accident (passenger)
Violence against
Other
Cause
Primary Concern
Adjustment disorder
Anger
Anxious
Body image
Low self-esteem
Low mood (depression)
Eating disorder
Dissociative disorder
Health anxiety
Phobia
Panic disorder
Personality disorder
PTSD
Seasonal effective disorder
Social anxiety
Stress
Self harm
Suicidal thoughts
Brief Description for the referral
*
Client Details
who is being referred?
Name
*
Postcode
*
Phone
*
Email Address
Doctors Information
If known
Dr Name
Surgery, secretary or admin name
GP surgery name
GP surgery postcode
Which CCG/ICB?
If Known
GP surgery phone number
GP surgery email address
Audiologist Information
Referrer name
Hospital or centre name
Address & postcode of provider
Phone number
Email address
Limb Loss Rehabilitation Referral
Referrer name
Name of Organisation
Address & postcode
Referrer, Phone number
Email address
Month/Year Limb Loss
Type
Leg above knee
Leg below knee
Double Leg
Single Hand
Double Hand
Arm
Double Arm
Other
Other
Current Limb Loss Counselling & Rehabilitation, what has client received.
Please add as much info as possible
Spinal Cord Injury Rehabilitation Service
Referrer name
Name of Organisation
Address & postcode
Referrer, Phone number
Email address
Month/Year Obtained SCI
Type
Tetraplegia/Quadriplegia
Incomplete – Some motor function
Incomplete – Some sensory function
Other
Other
Current SCI Counselling & Rehabilitation, what has client received.
Please add as much info as possible
Other
Referrer name
Name of organisation
Address & postcode of other
Phone number
Email address
NHS Talking Therapies England
Provider Service Name
ICB/CCG Name
Contact Name
Contact Email Address
Provider Postcode
Provider Contact Number
NHS Local Mental Health Wales
Provider Service Name
Contact Name
Address
Contact Email Address
Provider Contact Number
Doctor
Social Care & Social Services
Provider Service Name
Contact Name
Address
Contact Email Address
Provider Contact Number
Doctor
Medical Condition or Other
Provider Service Name
Contact Name
Address
Contact Email Address
Provider Contact Number
Doctor
Submit
If you are human, leave this field blank.
Δ
Loading Comments...
Write a Comment...
Email (Required)
Name (Required)
Website
