KidsAid

Client ID*

Name of person completing the form*

Please tick as relevant*

I am making a self-referral

I am making a referral on behalf of someone else

Full name of adult being referred*

Relationship to individual being referred*

Comment*

Job Title*

Name of Service*

Referrer Email*

Referrer Contact Number*

Is the person aware that you are making this referral?*

Please Explain*

Referred adult details

Date of Birth*

Age*

Gender*

Sexual Identity*

Marital Status*

Ethnicity*

Religion*

Nationality*

First Language*

Disability*

Please select the options below that most apply*

Is medication currently being taken?*

Detail*

Contact Number*

Email Address*

Referred address

First line of Address*

Second line of Address

Town*

County*

Postcode*

Are there any other services involved?*

Name of Service*

Type of support being received*

Contact Name*

Consent to contact them*

Has any form of therapeutic support ever been received?*

Primary Trauma*

Detail*

Secondary Trauma

Detail*

Length of time since trauma*

Primary emotional difficulties experienced*

Detail*

Secondary emotional difficulties experienced

Detail*

Please describe trauma and difficulties experienced in more detail*

Do you consider yourself to be a risk to yourself or others (if you are a professional completing this form please answer on the adults behalf)?*

Is there a preference for type of therapy/ gender of therapist/ ethnicity of therapist?

Is it possible to travel to KidsAid's therapy room in St. James, Northampton for the therapy sessions?

Is online therapy preferred?

Comment

Are there any days or times that a therapy appointment is not possible?

Is there any other information you wish to provide?

What do you hope will be gained from our support?*

Has funding been agreed for this therapy?*

How much can be contributed?*

Have all other potential funding sources been explored such as health and social services, support from relatives and other charitable sources?*

How did you hear about us?*

Detail*

Social Worker name & contact details*

Organisation name*

Adult Referral Form