Prometheus Referrals - Referral Form

Are you seeking

Therapeutic Support

Autism Spectrum Disorder (ASD) / Attention Deficit Hyperactivity Disorder (ADHD) Assessment

Psychiatric Assessment

Your Personal Details

We collect personal details so the Prometheus therapist can contact you. We ask for your GP details in case of urgent situations where we need to contact them. We collect your date of birth so the GP could identify you. We do not let the GP know you have contacted us as a matter of course.

Please complete the information below. Please note if there are any missing details we may not be able to process the referral for you.

Name *

Your date of birth *

Town / City *

Your email *

Telephone number *

Your GP practice *

Please Provide a Brief Summary of the Difficulty for Which You Would Like Support.

We find about 4-5 sentences provides us with enough detail to match you with the right therapist.
It's helpful to include details such as:

the nature of the difficulty (eg thoughts, feelings, behaviours)
any relevant life events
the impact of the difficulty on everyday life.

Your appointment preferences

When matching your referral with a Prometheus therapist, we will do our best to meet your preferences. However, please be aware that increased preferences can significantly increase wait times e.g. fewer therapists offer after work appointments. For certain difficulties, only one affiliated therapist may be suitable, limiting options to their clinic times.

Funding

Fee Agreement *

I understand that Prometheus Psychological Therapy Centre offers a referral service for private psychological assessment and therapy. All therapists charge fees for all services (please see the fees listed on the website). If your difficulties are complex, it is likely that you will be matched with a therapist with greater expertise with the relevant fee reflective of this.

I agree

Funding *

Please indicate how you will be funding.
Please note, unfortunately not all Prometheus therapists are registered with (only certain) providers - please email us if you would like more information.

Self Funding

Insurance / other

How Did You Find Us?

Review and Submit

Please review your request for Assessment / Therapy form and submit it if all of the enclosed details are correct.

You have stated that...

You have accepted that we are not a crisis service and are seeking referral-form/stage8.referral_type_ for yourself. You have also accepted the data agreement.

Your Details

Name

Your date of birth

Town / City

Your email

Telephone number

Your GP practice

Your Referral in Summary

Concerns

Brief summary

Your Appointment Preferences

Location Preferences

Availability Preferences

Funding Preferences

Fee Agreement

Not Accepted

You have indicated that you will be funding sessions via

Insurance / other

Insurance Provider

How Did You Find Us?

You have stated that you found us via

Not Specified

Private Assessment / Therapy Referral Form

Private Assessment / Therapy Referral Form

Step 1 of 8

Are you seeking

Your Personal Details

Please Provide a Brief Summary of the Difficulty for Which You Would Like Support.

Your appointment preferences

Funding

How Did You Find Us?

Review and Submit

Your Details

Your Referral in Summary

Your Appointment Preferences

Funding Preferences

How Did You Find Us?