Private assessment referral form

Please read this important information about what happens to your data:

Before completing our referral form, we need to ensure you understand what happens to the information you provide us. You must also have parental responsibility (https://www.gov.uk/parental-rights-responsibilities) for the child you wish to refer for psychological assessment / therapy

• We process the information provided in this form, along with any other correspondence with you, to enable us to see if there is a suitable affiliated therapist to whom we can make a referral, and if so, to match you with a suitable affiliated therapist.
• The information provided in this referral is reviewed by staff from Bristol Psychology Services.
• Sometimes we may be unable to identify a suitable independent therapist affiliated with the service. If this is the case, we will let you know and if possible, try to suggest suitable alternative services.
• If we are able to match the referral to a suitable affiliated therapist, the information you provide in this form, along with any relevant information from correspondence with you, is then made available to the therapists affiliated with the service.
• At times of high demand, we may operate a waiting list.
• In rare instances, where we are very concerned by information provided in this form, we may need to pass information on to other health or statutory agencies.
• We have provided more information about how we process data in our privacy policy.

Parent Consent

I have parental responsibility for the child I wish to refer for psychological assessment / therapy and I agree to you processing my child's data as outlined.
I do not have parental responsibility and / or I do not agree to you processing information as outlined.