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Shine Referral
Complex Care Counselling
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Shine Referral
Shine Referral
Who?
Who is completing this form?
*
Myself
Shine Representative
Disclaimer
Shine 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 the person you are referring them to DisabilityPlus and they have given permission for DisabilityPlus to contact them.
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Personal Details
Name
*
First
Last
*
Last
Postcode
*
Home Postcode
Email
*
Mobile
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My Spina Bifida
Spina Bifida and any Secondary Conditions
Ataxia
Autism
Deaf (BSL)
Deaf (hard of hearing)
Epilepsy
Motor Neuron
MS
Mutism
Limb Loss
Parkinson’s
Road Traffic Accident
Tinnitus
Sight Loss
Vestibular
Other
What Disability or Long Term Injury
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Is there anything you would like to share?
Brief Summary
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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?)
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Confirmation
Confirmation
Scope Employee Signature
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If you are human, leave this field blank.
Submit