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Menu
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
GEMs Advice
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:
GEMS as part of Solutions4Health request consent for your personal information to be stored and also to be shared with our workshop delivery facilitators who require this in order to send you information related to the workshop. We also use non-identifiable information for reporting purposes. If at any point, there are concerns relating to safeguarding we are obliged to share relevant information. You can also remove your consent for us to store and share data at any time by writing in to gems4health@nhs.net
Submit
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