Toggle navigation
Home
Scope Referral Form
Complex Care Counselling
Home
/
Scope Referral Form
Scope Referral
Who?
Who is completing this form?
*
Myself
Scope Helpline
Disclaimer
Scope are not affiliated with DisabilityPlus, we do not insist they support you. Our aim is to signpost you to a counselling service that supports people with Disabilities or long term injuries.
Disclaimer
Please confirm to person you are referring as given permission for DisabilityPlus to contact them.
Section Buttons
Personal Details
Name
*
First
Last
*
Last
Postcode
*
Home Postcode
Email
*
Mobile
Section Buttons
Disability or Long-Term Condition
Ataxia
Autism
Brittle Bones (OI)
Care Giver
Cerebral Palsy
Deaf (BSL)
Deaf (hard of hearing)
Downs Syndrome
Ehlers Danlos Syndrome
Epilepsy
Head Injury
Motor Neuron
MS
Muscular Dystrophy
Mutism
Limb Loss
Parkinson’s
Rare Genetic Disorder
Road Traffic Accident
Tinnitus
Sight Loss
Spina Bifida
Spinal Cord Injury
Vestibular
Other
What Disability or Long Term Injury
Section Buttons
Is there anything you would like to share?
Brief Summary
Section Buttons
Funding
I would like?
NHS Funding Application Only
Self-Paid
Self-Paid to Start & NHS Application
Other
Other
Past Funding
I have not had NHS funding
I have been declined by the local NHS service
I have had NHS counselling within the last 2 years
I have have NHS counselling in the past (After 2 years ago)
Other
Other
When approximately (NHS counselling?)
Section Buttons
Confirmation
Confirmation
Scope Employee Signature
Section Buttons
If you are human, leave this field blank.
Submit