Referrals

We charge a £95 non-refundable booking fee at the point of referral (which can be made by you or a professional). This initial fee will be deducted from the initial screening fee.

Client Details

Is this a referral for an adult or a child?(Required)

Child

Adult

1. Is this child a Looked After Child?(Required)

Yes

If yes please select(Required)

Foster Care

Residential Home

Special Guardianship

Kinship Care

Other

If Other, please specify(Required)

If yes, please state the responsible Local Authority(Required)

2. Parent / Carer Name/s (please include the names of all who have parental responsibility)(Required)

3. Address (child’s main address for correspondence) - All fields required(Required)

Street Address City County PostCode Country

4. Email (please include a single email address)(Required)

5. Phone number (please include the main contact number)(Required)

6. If contact details for all with parental responsibility have not been included, please add additional information (contact details and email address)

7. Child's name(Required)

8. Child's DOB(Required)

DD slash MM slash YYYY

9. Gender at birth

Male

Female

10. If you are a parent/carer of a young person between 16 and 18 years old enquiring on their behalf, we will need their explicit consent before organising any assessments. Please provide their email address and mobile number.

11. Does this child have an existing diagnosis? If so, please specify

11. School name and email contact(child assessment)

Please include a school email address as questionnaires need to be sent directly to school(Required)

13. Reason for Referral (please indicate what the main concerns that have led to this referral are, and what you feel the impact is – for the child, family, school etc.)(Required)

14. Service required(Required)

Autism Assessment

ADHD Assessment

15. Invoicing: Please provide name and email address / addresses for the person to be invoiced(Required)

16. Additional Invoicing information: e.g. Invoice to be split 50/50

17. How did you hear about us?(Required)

Magazine Advert

Online Advert

Organic Search (Google)

Recommendation

Social Media

Word of Mouth

Other (Please specify)

If other, please specify(Required)

1. Name of client to be assessed(Required)

2. DOB:(Required)

DD slash MM slash YYYY

3. Gender at birth(Required)

Male

Female

4. Address - All fields required(Required)

Street Address City County PostCode Country

5. Email (person filling out form)(Required)

6. Your phone number(Required)

7. If you are a parent/carer of a young adult aged 18 to 21 enquiring on their behalf, we will need their explicit consent before organising any assessments. Please provide their email address and mobile number.

8. If young adult is in full time education, please include a school/college/university email address and contact details as questionnaires need to be sent directly

9. Reason for Referral (please indicate what the main concerns that have led to this referral are, and what you feel the impact is – on you, work, relationships etc.)(Required)

10. Service required(Required)

Autism Assessment

ADHD Assessment

11. Invoicing: Please provide name and email address / addresses for the person to be invoiced(Required)

12. Additional Invoicing information: e.g. Invoice to be split 50/50

13. How did you hear about us?(Required)

Magazine Advert

Online Advert

Organic Search (Google)

Recommendation

Social Media

Word of Mouth

Other (Please specify)

If other, please specify(Required)

In submitting this enquiry you agree that your data will be processed in accordance with our privacy policy

Credit Card(Required)

Referral fee (including VAT)

Please note the referral fee is nonrefundable

Price:

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What our clients think

Thank you all for your time and hard work, it’s been such an easy process

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Berkshire Psychology, Wyvols Court, Basingstoke Road, Swallowfield RG7 1WY.
Telephone: 0800 001 6897 Email: admin@berkshirepsychology.co.uk

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Berkshire Psychology, Wyvols Court, Basingstoke Road, Swallowfield RG7 1WY.
Telephone: 0800 001 6897 Email: admin@berkshirepsychology.co.uk

Privacy Notice
Cookie Policy
Sitemap

Berkshire Psychology is a trading name of Berkshire Independent Psychology Services Ltd
Registered Office: Wyvols Court, Basingstoke Road, Swallowfield, RG7 1WY
Registered in England and Wales No. 08232415.

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