Referrals

Make a referral.

A secure referral form for SENCos, school staff and other professionals referring a child or young person to Fieldfare Psychology. Parents and carers have a separate form.

Who this form is for

This form is for SENCos and school staff, and other professionals referring a child or young person to Fieldfare Psychology.

If you are a parent or carer, please use the family referral form instead.

If you would prefer to talk things through before completing the form, you are welcome to get in touch by email.

What you'll need

Parent or carer consent (required) — either their signed consent form to upload (PDF / Word), or their email address so we can send them a secure e-signature form.
The child or young person's date of birth, school and year group.
A short summary of the reason for referral.
Any supporting reports you would like to share (optional).

Your information

Submissions are sent securely and directly to the practice. This website does not store referral information.

See the privacy notice for how information is collected, used and stored.

Fields marked * are required. Please do not include more detail than is necessary in the reason box. For parent or carer consent you can either upload a signed consent form (download the PDF or editable Word version for them to complete), or send them a secure e-signature form to sign.

Referrer

Your name *

Your email address *

We email the proposed visit date here, so an address is needed. You can add a phone number after it if you like.

Child / young person

Child / young person's name *

Date of birth *

School / setting *

Year group *

Referral

Type of referral *

Enhanced consultation1 day · half a day in school Full assessment2 days · one day in school

What's the difference?

Enhanced consultation: the psychologist visits school for half a day (either the morning or afternoon session) and completes consultation with parents or carers, consultation with school staff, and an observation of the child or young person. An additional half-day is used to produce a short report.
Full assessment: the psychologist visits school for a full day and completes consultation with parents or carers, consultation with school staff, an observation of the child or young person, and direct work with them, which may include psychometric assessment. An additional full day is used to produce a comprehensive report detailing specific, measurable outcomes and, where possible and appropriate, quantifiable provision.

Reason for referral *

A short summary of your concerns. Do not include anything you would not want held in a clinical record.

Parent / carer consent *

Upload a signed consent formYou already have the parent or carer's signed form to attach. Send an e-signature form to the parent / carerWe email them a secure form to sign. The referral is held until they've signed.

Supporting documents (optional)

Optional. Up to 10 files / 50 MB total (including the consent form). Same file types.

Consent

I confirm the parent or carer is aware of this referral and agrees to it. *

I confirm I have the necessary consent to share this information (which may include special-category data) with Fieldfare Psychology, and I have read the privacy notice. *

Make a referral.

Thank you — your referral has been received.