Adult Referrals

If you’re a parent or carer and looking for support, please don’t hesitate to get in touch – our team is here to guide you through the process and help you find the best support possible.

Adult Referral Form

About the Person Completing this Form

Are you making a self-referral?
Select self referral type
Referrer name
Referrer name
Relationship to individual being referred
Relationship to client
Other relationship type
Other relationship type
Job title
Job title
Referrer email address
Referrer email
Referrer phone
Referrer phone
Is the person aware that you are making this referral?
Client aware?
Please explain
Reason client unaware

About the Adult being Referred

First name
First name
Last name
Last name
Date of birth
Date of birth
Gender
Client's gender
Ethnicity
Ethnicity
Nationality
Nationality
First language
First Language

Referred Individual Residing Address

Address line 1
Address line 1
Address line 2
Address line 2
Address line 3
Address line 3
Town or city
Town or city
County
County
Postcode
Postcode
Country
Country

Disability or Additional Needs

Does the individual have a disability or additional needs?
Disability or additional needs?
Notes
Disability notes
If yes, please select the options below that most apply
Select options

Referred Individual Medication

Is the individual taking medication?
Medication?
Medication details
Medication details

Referred Individual Support

Are there any other services involved?
Other support?
Name of service
Name of service
Type of support
Type of support
Contact name
Contact name
Consent to contact?
Consent to contact?

Referred Individual Trauma & Emotional Difficulties

Trauma (select as many as relevant)
Select options
Other Trauma Details
Other trauma details
Length of time since trauma
Time since trauma
Emotional difficulties (select as many as relevant)
Select options
Additional information
Trauma notes

Referred Individual Therapeutic Support

Has the individual had therapy before?
Other therapeutic support?
Therapy type
Type of therapy
Therapy organisation
Location of therapy
How many therapy sessions?
Number of sessions
Therapy end date
Date therapy ended
Reason therapy ended
Reason therapy ended

Referred Individual Risk

Is the individual considered to be a risk to themselves or others?
Client risk?
Risk details
Risk details

Additional Information

How did you hear about us?
Referral source
Referral source details
Referral source details
Able to travel to KidsAid therapy rooms?
Able to travel?
Any times a therapy appointment is not possible?
Are there any days or times that a therapy appointment is not possible?
Is there a particular preference for therapy?
Therapy preference?
Has funding been explored?
Funding agreed?
Contribution amount
How much can be contributed?
Is there any other information you wish to provide?
Additional information