№ files_lp_4_process_1_51885
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Character count: 1474
File size: 56 KB
A self-referral form for patients considering a vasectomy procedure, which collects personal and medical information prior to referral acceptance.
Note:
Year
Topic:
Healthcare
Document Type:
Referral Form
Organization:
Don Valley Healthcare & The Scott Practice
Target Audience:
Patients considering vasectomy
Price: 8 / 10 USD
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The product description is provided for reference. Actual content and formatting may differ slightly.
Note:
Year
Subject:
Health, Male Sterilization
Document Type:
Informational Brochure
Target Audience:
Men considering sterilization
Year:
Not specified
Country:
United Kingdom
City:
Derby
Service:
Autism Assessment Service
Healthcare system:
NHS
Target population:
Adults aged 18 and over
Eligibility criteria:
Clinical need for autism assessment
Document type:
Self-referral form and screening questionnaire
Associated assessment tool:
Autism Spectrum Quotient (AQ-50)
Institution:
Adult Neurodevelopmental Services
Address:
St Andrew’s House, 201 London Road, Derby DE1 2SX
Contact email:
[email protected]
Contact telephone:
0300 123 4574
Consent requirement:
Yes
Related services referenced:
National Autistic Society, British Psychological Society, Autistica, Embrace Autism
Administrative process:
Referral review and questionnaire-based triage
Note:
Year
Region / City:
Thames Valley
Topic:
Criminal / Regulatory Proceedings
Document Type:
Guidance
Institution:
General Medical Council
Author:
General Medical Council
Target Audience:
Doctors in Training
Description:
A guidance document detailing the process for self-referring to the GMC for doctors in training, addressing criminal or regulatory issues, health concerns, and other relevant incidents.
Year:
2023
Region / city:
Powys
Topic:
Audiology services, self-referral process
Document type:
Referral form
Organization / institution:
Powys Teaching Health Board, Betsi Cadwaladr University Health Board
Author:
Powys Teaching Health Board
Target audience:
Patients seeking audiology services
Period of validity:
Ongoing
Approval date:
Not provided
Date of amendments:
Not provided
Country:
Scotland
Organisation:
VoiceAbility
Document type:
Self-referral form
Service type:
Advocacy services
Target group:
Residents of Scotland
Submission method:
Email submission
Email address:
[email protected]
Subject areas:
Health advocacy, Mental health advocacy, Social care advocacy, Carer advocacy, Learning disability advocacy, Older people’s advocacy, Child protection advocacy, Adult support and protection advocacy, Housing advocacy, Substance use advocacy, Transitions advocacy
Data protection:
Processed in accordance with Privacy Notice
Diversity monitoring:
Gender, sexual orientation, ethnic group, religion, preferred pronouns
Access requirements:
Interpreter, physical access needs, Makaton, British Sign Language (BSL), assistive communication, Easy Read, same-gender advocate request
Note:
Year
Subject:
Musculoskeletal Physiotherapy
Document Type:
Self-referral Form
Organization / Institution:
NHS
Target Audience:
People aged 16 or over with musculoskeletal problems
Region:
Lancashire and South Cumbria
Country:
United Kingdom
Service:
Integrated Hearing Service for Age Related Hearing Loss
Minimum Age:
50 years+
Document Type:
Self-Referral Form
Healthcare System:
NHS
Related Service:
Community Adult Hearing Service
Issue Date:
February 2024
Providers:
Audiology AQP service providers
Named Providers:
Specsavers; Outside Clinic; Galloways
Required Information:
Personal details; NHS Number; GP Surgery details; Medical history; Hearing-related symptoms
Eligibility Criteria:
No reported exclusion symptoms within specified timeframes
Administrative Context:
Self-referral pathway requiring direct contact with chosen provider
Year:
2020
Organization:
The Leeds Teaching Hospitals NHS Trust Print Unit
Document type:
Referral form
Target audience:
Pregnant or post-partum patients
Contact email:
[email protected]
Referral code:
WQN1327
Eligibility:
Less than 12 weeks pregnant or within 12 months post-delivery
Required information:
Full name, NHS number, address, date of birth, phone number, email, reason for referral, relevant medical history, interpreter requirement
Year:
2018
Region / City:
Herefordshire
Topic:
Mental Health, Counselling
Document Type:
Referral Form
Organization:
Herefordshire Mind
Author:
Pandora Jones
Target Audience:
Individuals seeking counselling services
Effective Period:
Not specified
Approval Date:
Not specified
Amendment Date:
Not specified
Region:
Moray
Country:
Scotland
Organisation:
VoiceAbility
Document type:
Self-referral form
Subject:
Advocacy support services
Target group:
Residents of Moray
Submission method:
Email submission to [email protected]
Service areas:
Mental health, health, social care, alcohol and drug support, learning disability, older people, child protection, adult support and protection, transitions
Data processing:
In accordance with Privacy Notice
Content elements:
Personal details, access needs, meeting information, diversity monitoring data
Year:
2023
Region / city:
West Yorkshire
Theme:
Health and care, consent, Dynamic Support Register
Document type:
Consent form
Organization:
West Yorkshire Health and Care Partnership
Author:
West Yorkshire Health and Care Partnership
Target audience:
People seeking to be added to the Dynamic Support Register, parents or guardians of individuals under 16
Period of validity:
N/A
Approval date:
N/A
Date of changes:
N/A
Year:
2023
Region / City:
Buckinghamshire
Topic:
Mental Health, Counselling Services
Document Type:
Referral Form
Organization:
Bucks Mind
Author:
Unknown
Target Audience:
Individuals seeking counselling support
Period of Validity:
Ongoing
Approval Date:
Not specified
Amendment Date:
Not specified
Year:
2023
Region / City:
Kirklees, Huddersfield
Topic:
Psychological Therapy Referral
Document Type:
Referral Form
Organization:
Kirklees IAPT
Author:
N/A
Target Audience:
Individuals seeking psychological therapy
Period of Validity:
N/A
Approval Date:
N/A
Modification Date:
N/A
Note:
Year
Organisation:
NHS Western Isles Podiatry Service
Document Type:
Self-referral form
Service Area:
Western Isles, Scotland
Subject:
Podiatry assessment and foot health conditions
Intended Applicants:
Patients seeking podiatry services
Submission Method:
Email or form return to [email protected]
Required Information:
Personal details, GP practice, medical history, medication, allergies
Clinical Criteria:
Foot ulcer, circulation concerns, intense pain, ingrown toenail, nail conditions, painful corn
Additional Information:
Duration of problem and availability for appointments
Support Options:
Communication support including Language Line
Emergency Contact Details:
Name, relationship, telephone number
Referrer Information:
Name, date, relationship to patient if applicable
Year:
Not specified
Student name:
Not specified
Form:
Not specified
Date:
Not specified
Type of document:
Self-referral form
Institution:
School
Target audience:
Students seeking counselling
Purpose:
To collect information on student well-being and support needs
Confidentiality note:
Information may be shared if safety concerns arise
Parental consent required:
Under 13 years old
Prior support accessed:
Yes/No (to be specified by student)
Other agencies involved:
Yes/No (to be specified by student)
Note:
Year
Topic:
ICT Products and Services
Document Type:
Order Form
Note:
Year
Year:
2006
Region / City:
Australian Capital Territory
Subject:
Legal procedures, subpoena
Document Type:
Court Form
Issuing Authority:
Court of the Australian Capital Territory
Author:
Not specified
Target Audience:
Legal professionals, defendants, plaintiffs
Effective Period:
N/A
Approval Date:
N/A
Amendment Date:
N/A
Note:
Year
Topic:
Physiotherapy, Workplace Injury Rehabilitation
Document Type:
Form
Organization / Institution:
WorkSafeBC
Target Audience:
Employers, Physiotherapy Providers