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DisabilityPlus Self-Referral Form
Complex Care Counselling
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DisabilityPlus Self-Referral Form
Self-Referral
General
Preferred
*
Assessment Session for Free Funding
Self-Paid & Assessment Session (Free Funding)
Self-Paid only
Employment Support
Other
Other
How would you like to be contacted?
Email
Text
Phone
Other
Other
How did you find us?
Internet Search
Social Media
Recommendation
MS-UK
Scope
Amputation Foundation
Other
Other
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Your Referral
Disability or Injury?
Autism
Brittle Bones
Brain Injury
BSL Counselling England
BSL Counselling Wales & Scotland
BSL Counselling Ireland
Ehlers-Danlos Syndrome
Endometriosis
Cerebral Palsy
Downs Syndrome
Hearing Loss
Muscular Dystrophy
Continued
Limb Loss
Lumber Spondylosis
Multiple Sclerosis
Rare Genetic Disorders
Road Traffic Accident
Skeletal Dysplasia
Spina Bifida
Spinal Cord Injury
Sight Loss
Other
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The NHS ASD
DisabilityPlus are not able to apply for Free Funding. Visit your General Practice, they can refer you to specialist NHS Funded ASD service .
The NHS BSL
DisabilityPlus are not able to apply for Free Funding in Ireland. Please visit your GP for mental health counselling.
The NHS BSL
DisabilityPlus are not able to apply for Free Funding in England. SignHealth have a national contract with NHS England. Their website:https://signhealth.org.uk/with-deaf-people/psychological-therapy/
Road Traffic Accidents
DisabilityPlus are not able to apply for Free Funding if you have NOT obtained a disability through the accident.
Address & Contact
Your Name?
PostCode?
Date of Birth
00/00/0000
Phone Number?
Email
*
Gender?
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Summary
Brief Summary?
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