GP Referral Form

Please fill in the below information for the individual you are referring.

Personal Details

First Name

Last Name

Date of Birth

Address

Phone Number

GP information

As the referring GP, we need to know your full contact information, including your surgery's address, which must be the practice the person being referred is registered to.

Surgery Name & Address

Please enter your GP Practice Code (e.g., A 00000)

Please add your professional contact details below. The address must be an NHS.net address only, and a surgery email wherever possible.

First Name

Last Name

Phone Number

Which integrated care board (ICB) is your GP surgery part of?

Which responsible borough or locality within the ICB is your surgery located in? (enter n/a if not applicable) e.g. NHS South West London ICB - Kingston Upon Thames

Patient Information

We only offer remote assessments through Right to Choose. Please ensure the patient is aware and comfortable with this. What type of assessment are you referring this individual for?

Child Autism

Adult ASD

Adult ADHD

Adult ADHD and Autism

Please provide a brief medical summary of the patient. This should include any observations relating to the reasons for the referral, and any other relevant known diagnoses. You can upload any documentation on this on the next question.

Please attach any documents relevant to the patient's past medical history. Please ensure the document type is doc, docx or PDF.

What is the patients NHS number?

What is the patients preferred spoken language?

Does the patient require any reasonable adjustments?

Please provide us with written and signed letter on headed paper for this referral. Please ensure the document type is doc, docx or PDF.

Please provide the email address for the GP practice so we can email you following this referral.

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If you have questions, please don't hesitate to get in touch, we’re always happy to help.

GP Referral Form

Personal Details

GP information

Patient Information

Start your journey today

Need more information?

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