GP–Psychologist Consultation Request Form
This form is for GPs seeking a professional consultation with a psychologist regarding a shared client. It is not a referral for assessment, but a case discussion service for diagnostic clarification, treatment planning, or formulation support.
Referring GP Name:
*
Practice Name:
*
Practice Location:
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GP Email (for confirmation and case notes):
*
GP Phone:
*
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Client Overview
Please do not include NHI or identifying details without consent.
Client Name:
*
Client Date of Birth:
*
Client NHI
*
Client has consented to this case being discussed:
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Yes
No
Please outline the focus of your enquiry. You are welcome to include diagnostic queries, behavioural patterns, differential concerns, or system-level formulation questions.
*
Are there particular diagnoses, presentations, or behaviours you’d like to explore further?
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Have there been any previous assessments or interventions (e.g. CAMHS, psychiatry, educational)?
*
Please upload any relevant documents or reports:
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Availability for Consultation
Do you have any preferences for timing (e.g. specific days or times)?
*
Is this case urgent or time-sensitive?
*
No
Some Urgency
Urgent (please describe)
Please complete the declaration
*
I confirm that I am a registered medical practitioner and this request is for a professional case consultation
I understand this is a private service and consultation fees apply
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