Digital Referral Form

Professional Referral Form
Document Title
Referral Date

DayMonthYear
Email Address Sender FT
Medway RIVER Email Address
No Reply Email Address
Does your patient live in the Medway area?

YesNo

Support Services
Unfortunately, we can only work with individuals that live within the Medway area. If your service user is unsure what area they fall under, please enter the postcode into the Government Local Council website linked below. Please note that we only cover areas with a local authority of Medway.

https://www.gov.uk/find-local-council

Otherwise, please contact us for more information; medway.referrals@forwardtrust.org.uk

Substance(s) requiring support?*
Description of use and reason for referral*
Does the person you are referring consent to this referral?*

Neurodiversity
Does the client have or think they have a neurodiverse condition e.g. autism, ADHD, dyslexia?*

YesNo
If yes, please specify which neurodiversity condition(s)

ASD: Autism/Autistic Spectrum DisorderADHD: Attention Deficit Hyperactivity DisorderDyscalculiaDyslexiaDyspraxiaTourette’s SyndromeOther

Referrer Details
Referrer Name*

First NameSurname
Role*
Agency*
Telephone number*
Email*
Does {yourPatients} consent to being referred to the Medway RIVER Treatment & Recovery Service?*

YesNo
Would you like to be kept updated on the outcome of your referral?*

YesNo

Supporting Documentation
Please upload any supporting documentation which may assist The Forward Trust with processing the referral for {yourPatients}.

Supporting documents can include medical summary information obtained from healthcare professionals and/or assessment and risk management plans from community support organisations.
Cancelof
Should be Empty: