FPG Initial Referral

Initial Referral - 3rd Party

IR2
Complete this form if you are:
- A company or organisation
- Local Authority
- NHS CCG/Trust
The information you provide below will be submitted using encryption and stored on our secure case management system. It will only be shared with the practitioners that work with you.

A Case Manager will be in contact within 24 hours to discuss your referral and if accepted, an estimate of fees will be submitted along with our general terms and conditions.
Referrer Details

This is the person completing the form.
I am representing a:*

Company / OrgNHS Trust/CCGLocal AuthorityOther
Name of organisation*
I am considering the following services*

TherapyAutism Diagnostic AssessmentEducational AssessmentExpert Witness
Your Name*

PrefixFirst NameLast Name
Position*
Director, Manager, HR Advisor
Contact Number*
Email*
example@example.com
Subject Information

This is the client, employee, or contractor you wish to refer. If you do not wish to provide the name of your client at this stage please leave this blank.
Name

First NameMiddle NameLast Name
Gender*
Age*
Mobile Number
Email
example@example.com
School/College/University
Local Authority
Please let us know which local authority you pay your council tax to. This is to avoid conflict of interest with certain Educational Psychologists we employ.

Current Situation

Please briefly describe your current situation or the situation of the indivdual concerned. If you prefer, we can also accept word or pdf documents to assist us in reviewing your referral
Current Situation*

Please provide a brief description of the current situation including your relationship to the individual.0/500
What you are seeking*

Please indicate your initial thoughts on what you would like us to do0/500
Upload any relevant documentation

Browse Files

Cancelof

Fees and Funding

As a 3rd party referral, we need to understand how our fees may be funded. We also need to know whom to address our estimate of fees too. Please note that by providing the information below this is not confirmation or agreement to deliver or fund any services.
Type a question

Part FundedFully Funded
Part Funded Services
Please provide further information on what potential funding is available
Whom should our estimate of fees be addressed to?

Direct to meSomeone else
Name

First NameLast Name
Department
Email
example@example.com
Invoicing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is a PO number required by your organisation for invoicing?

YesNo
Please note that if a PO number is necessary for invoicing, we will require this prior to any services being delivered or appointments offered.

Following acceptance of our estimate of fees and terms and conditions we also require confirmation via email or letter that our fees have been authorised. The following declaration must be used alongside the signature of the authorised party.

"I am authorised by (company/trust/local authority) to instruct the Family Practice Group to deliver out the requested services and confirm I am authorised to confirm acceptance of your terms and conditions and estimate of fees"

Consent

Please review your form to ensure you have provided the correct information and when you are satisfied, please sign below in the space provided. You may use your finger, stylus or mouse. Once submitted it will be transmitted using encryption to our Case Management Team who will respond within 24 hours.
Whom should we contact regarding this referral?*

MyselfSubjectOther
Contact Details further information
If you have selected other please provide further information
How should we contact you or the subject named in the referral?*

Mobile PhoneEmailOther
Can we leave a message on an answering phone*

YesNo
I confirm that the information provided above is true and accurate. I am happy and consent to the Family Practice Group to use the information provided to assess for suitability to provide psychological services to the individual concerened.
Please provide your signature below*

Clear
Should be Empty:

Referrer Details