Brief Therapy Support Service
106 Deepdale Road
Preston
PR1 5AR
07971-569042
btssfinance@gmail.com
vicky@btss.org.uk
www.btss.org.uk
REFERRAL FORM
Surname:
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First Name(s):
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Address:
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Date of Birth:
Post Code:
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NHS Number:
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date.
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Tel:
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First Language:
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Mobile:
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Ethnicity:
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Email:
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Other Languages:
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What is best way to contact person to make initial appointment?
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Name of GP:
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GPs Phone
Number:
Address of GP:
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Name of Significant Other:
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Address (if different from above):
Does person consent to referral?
Male
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Name & Address of Commissioner for invoice purposes
Name:
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Address:
Secure Email:
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Phone Number:
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Date Funding Agreed: Click here to enter a date.
Inv/Ref Number:
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Reason for Referral: Include any relevant information/medical history/conditions and your comments on the
child’s communication skills and feeding [for further guidance see checklist page 2]
☐ Diagnostic Assessment
☐ Therapy Sessions
☐ Support Worker
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Signature
Printed NAME and TITLE of person making referral
*Please return completed form to NHS Commissioning Support Unit, Jubilee House, Lancashire Business Park Leyland PR26 6TR
14/06/2013
DATE
Service Refer if…(examples only)
Diagnostic
Assessment
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Therapy
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Support
Worker
Literal understanding of words and situations
Poor social interaction with peers
Cannot maintain meaningful conversation on a range of topics
Difficulty coping with changes in routines
Person’s daily life is limited by inflexible thinking, not understanding social situations,
sensory sensitivities, social anxiety
Person has routines, obsessions or topics of intense interest
Person has repetitive behaviour such as rocking, flicking fingers, touching hair
Person wishes something to be different in their lives
The changes the person wants are something that can be achieved through talking with a
therapist (e.g. getting along with others, feeling better, moving forward)
The changes the person wants are within the remit of therapy (e.g. are not about moving
house, getting benefits, getting a job etc.)
Person requires assistance doing activities of daily living, such as someone to help organise
shopping list, teach transportation routes, help manage anxiety when out, help maintaining
own home, help making and attending appointments, help reading post, help with
budgeting / banking.
RISK (MUST be answered by circling one)
Has the person EVER been subject to a behaviour order or ASBO?
YES
NO
Has the person EVER been physically violent with family
YES
NO
Has the person EVER been physically violent with professional staff
YES
NO
Is this referral appropriate for a lone worker service
YES
NO
If any ‘YES’ circled, please explain below:
*Please return completed form to NHS Commissioning Support Unit, Jubilee House, Lancashire Business Park Leyland PR26 6TR
Please write any other information you would like us to know in the space below. Thank you
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*Please return completed form to NHS Commissioning Support Unit, Jubilee House, Lancashire Business Park Leyland PR26 6TR