REFERRALS FOR TAILORED PSYCHOLOGICAL SUPPORT

Refer yourself, your child, or a client—expert care starts here.

MAKE A REFERRAL

Ready to Refer? Fill out our quick referral form below and let’s get started! We aim to respond within 48 working hours.

Our service specialises in Trauma/PTSD, OCD, and ADHD. We only accept referrals where one of these is the primary concern, however co-occurring conditions are welcome.

REFERRAL OPTIONS

To make a referral, click the box that best describes your situation.

01

Self-Referral / Parent Referral

For individuals, parents, or carers looking to access support directly. Use this form if you’re seeking therapy or ADHD strategy sessions for yourself or your child.

02

Professional Referral

For professionals (e.g., Social workers,Solicitors GPs, school staff) referring on behalf of a client or family.
Use this form if you're referring someone as part of your professional role.

Self referral/parent referral. If you are making a self referral you must be over 18 years old

Where further information is requested (e.g. incident history, professional involvement, or safeguarding concerns), you may provide this in bullet point format.

Client Details

Full Name of Person Being Referred*

Date of Birth*

Age (Must be 7 or over)*

Gender*

Pronouns (optional)

Ethnicity*

Primary Language Spoken*

Address (including postcode):*

Can sessions be delivered*

Are there any accessibility or communication needs we should be aware of?*

Details of Person Completing This Form

Your Name*

Your Relationship to the Person Being Referred: (e.g. parent, carer, self, guardian)*

Contact Number*

Email Address*

Preferred Method of Contact*

Education & Schooling (for children and young people)

Current Education Status (tick all that apply)*

Attending mainstream school full-time

Attending part-time

School avoidance/refusal

Withdrawn from school (home educated)

Not currently in education

Specialist setting / SEND school

Name of school or education provider*

Does the child/young person have an EHCP (Education, Health & Care Plan)?*

Please provide any relevant details about school support or challenges*

Neurodiversity & Additional Needs

Please tick any that apply or provide further detail below. No formal diagnosis is required.*

Autism / ASC

ADHD

Dyslexia

Dyspraxia / DCD

Sensory Processing Differences

Tourette’s or tics

Social Communication Needs

Learning Disability

Speech, Language & Communication Needs

Other or awaiting diagnosis

Please provide any further information about neurodiversity or support needs*

Reason for Referral

Please tick any areas where support is being sought, and use the space below to provide more information*

Obsessive-Compulsive Disorder (OCD)

Post-Traumatic Stress Disorder (PTSD) / Trauma

Anxiety, panic, stress

Low mood or depression

Emotional regulation

Executive functioning (e.g. planning, routines, attention)

Parenting strategies (neurodiversity or trauma-informed)

School or education difficulties

Identity/self-esteem

Other mental health needs

Please describe the current concerns and what support is being sought*

Practical Preferences & Availability

Preferred session format*

Preferred days or times (e.g. after school, evenings)*

Is there anything we should be aware of when planning sessions?*

Medical & Safety Information

Current or past medical or mental health diagnoses*

Any current medications*

Are there any known physical health conditions?*

Has there been any history of self-harm or suicidal thoughts?*

Are there current safeguarding concerns (e.g. domestic abuse, substance misuse, risk of harm)?*

Family & Household Information

Are there any other children in the home?*

Yes

If yes, please provide ages

Are there any concerns within the family home you’d like us to be aware of? (e.g. conflict, emotional wellbeing, domestic abuse, housing difficulties)*

Legal or Involvement with Services (optional)

Are you currently involved with any services (e.g. Social Care, CAMHS, SENCO, School Nurse)?

Yes

If yes, please list key professionals and roles

Are there any upcoming key dates (e.g. court hearings, meetings)?

Helping Us Understand the Full Picture

Please provide any information that will help us understand the context, needs, and strengths of the person being referred. Sharing relevant background helps us tailor our approach and offer the right support from the start. See below

What are the current concerns?*

Is there any relevant background that could help us better understand the person’s needs?*

When did this start — and what might have triggered it?*

What’s making things harder or keeping the problem going?*

What’s going well or what supports are in place?*

Additional Comments

Please use this space to share anything else you'd like us to know

By ticking this box, you confirm that you have read and agree to our Privacy Notice, and consent to us collecting, storing, and using your information to process your referral. Your data will be stored securely and handled in accordance with UK data protection law.

Professional Referral Form

This referral form is for professionals seeking support for a client through Amelia Finch services. Please complete all relevant sections thoroughly to support appropriate triage and service provision.

Client Consent: Please ensure the client has been informed and consents to this referral. If consent is not possible, referrals must comply with safeguarding duties.

Where further information is requested (e.g. incident history, professional involvement, or safeguarding concerns), you may provide this in bullet point format

Referrer Details

Full Name*

Role / Job Title*

Organisation*

Phone Number*

Email Address*

Date of Referral*

Client Details

Full Name*

Date of Birth*

Age*

Gender*

Ethnicity*

Current Address*

Preferred Contact Number*

Email Address (if appropriate)

Can the client engage in*

Face-to-face sessions

Online sessions

Either

Does the client consent to this referral?*

Yes

If No - Referral made under safeguarding obligations (please explain below) [Text Field – brief justification if no consent]

Presenting Issues & Mental Health History

Primary reason for referral*

Client’s medical history and diagnosis (if applicable)*

Known safeguarding concerns (past or present)*

Has the client ever experienced suicidal ideation or self-harm?*

Yes

If yes, please provide brief details, including dates, what occurred, and the outcome*

If yes, include any relevant convictions (historical or pending) or offending behaviour*

Has the client ever had contact with criminal justice services?*

Yes

Social and Professional Context

Is the client open to social care or early help services?*

Yes

Type of involvement*

Early Help

Child in Need (CIN)

Looked After Child (LAC)

Other / Previous involvement

Please list other professionals or services currently involved with the client (e.g. GP, Social Worker, School, Legal Guardian, CAMHS)*

Any upcoming significant dates (e.g. court hearings, care planning meetings, legal deadlines)*

Specific Context / Trauma Background

Has the client experienced any of the following? (tick all that apply and briefly describe):*

Road Traffic Accident / Personal Injury

Burns / Medical trauma

Domestic abuse (past or current)

Substance misuse (by client or parent/carer)

Childhood abuse / neglect

Sexual violence or exploitation

Trauma from migration, war or displacement

Other significant trauma (please describe)

Any children linked to the client (if an adult)?*

Yes

If yes, please list their ages and any relevant concerns (e.g. safeguarding, contact arrangements):*

Helping Us Understand the Full Picture

What are the current concerns?*

Is there any relevant background that could help us better understand the person’s needs?*

When did this start — and what might have triggered it?*

What’s making things harder or keeping the problem going?*

What’s going well or what supports are in place?*

Additional Information

Please use the space below to provide any further relevant context or information that would support the referral or clinical understanding.

Additional Comments

By submitting this form you confirm*

You have obtained appropriate consent or are acting in accordance with safeguarding legislation.

The information provided is accurate to the best of your knowledge.

You understand that submission of this form does not guarantee acceptance or availability of services.