Private assessment referral form

For whom are you seeking a referral?


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

Before completing our referral form, we need to ensure you understand what happens to the information you provide us.

  • 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


Data processing


Your Personal Details

We collect personal details so the affiliated 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.

Child's Personal Details

We collect this information to enable us to match your child with a suitable therapist. We do not inform your child's GP as a matter of course that you have contacted us, but we require this information in case we or the affiliate needs to contact the GP in urgent situations.

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

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 an affiliated 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 affiliates offer after work appointments. For certain difficulties, only one affiliated therapist may be suitable, limiting options to their clinic times.

Please indicate your preferences for appointment location

Please indicate your preferences for the therapist's gender:

Please indicate your availability to attend appointments (please select all possible options)There are currently very few affiliates offering evening or Saturday appointments.

Please indicate your preferences for the therapy format:

Fee Agreement

I understand that BrPS is a referral service for private psychological assessment & therapy and all therapists charge fees for all services (approx. £80-95 per hour).

Funding

Please indicate how you will be funding.
Please note, unfortunately only a minority of affiliates are registered with (only certain) providers - please email us if you would like more information.