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Self-Paid Referral
DisabilityPlus Self-Paying Referral Form
The information you provide on this form is strictly confidential and will only be used to support your care. Without your explicit consent, we will not share your details with any third parties.
Select Option
*
Self-Paid Counselling
PIP Assessment
Select Option
*
Self-Paid Counselling
PIP Assessment
Price for Sessions
For the first session its £50, thereafter its £180 for every 3 sessions (3x£60)
Your Details
Name
*
First
Name
*
Age
*
Last
Gender
Email
*
Phone
Postcode
*
Disability
Disability
ADHD
Amputee
ASD
Ataxia
Cerebral Palsy
Deaf -BSL
Deaf-Oral
Blind/Sight Loss
Epilepsy
Multiple Sclerosis
Osteogenesis Imperfecta
Rare Genetic Disorders/Disease
Spina Bifida
Spinal Cord Injury
Tinnitus
Vestibular Disorder
Muscular Dystrophy
Other
Other
How did you hear about us?
Rosie Jones Foundation
Other
What Rare Genetic Disorder/Disease
What would you like support with?
Submit
If you are human, leave this field blank.
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