You can download our referral form below, please read the following guidance before filling in or sending a referral.
Please read our referral and provision criteria to ensure the referral is appropriate for our service and within the remit of the specialised service that we are commissioned to provide.
You may also want to review our local services resource pack to see the kind of equipment that is expected to be provided via local, rather than specialised, services.
Please also check that the client is from within an area we are currently covering.
We run a satellite service for provision to adults in Sheffield. In Sheffield referrals for AAC or EC for adults should be sent via the Neurological Enablement Service (NES)
Filling in the Form
We have completed an example referral form which may help with filling it in. You can download the blank forms for completion below.
Goals of referral
The Provision only (QA) option should only be selected if you wish to refer a client but do not feel you require additional assessment support from the team. In these cases it would be expected that the referral should be accompanied by a report detailing the assessment and recommendations. Submitting a request via this route does not guarantee in any way that the equipment requested will be provided. Professionals selecting this route would have demonstrable specialist skills to be able to assess, recommend and implement equipment with minimal additional input. Do not select this option if you have not submitted a referral to the team before.
Environmental Control Considerations
It must be noted that provision of Environmental Control equipment can only be considered as assistive technology. It must never take the place of any personal care input deemed essential to a specific client and their personal circumstances and situation. It must never be relied on as a safety critical means of attention calling – other procedures must be in place to ensure the safety of the individual.
As detailed in the EC criteria, we are unable to provide door, window and curtain openers (our systems can link with these but we do not provide). A referral needs to be made to the local Equipment and Adaptations service for these adaptations.
Please also note that we are also unable to provide assessment and provision for computer access when it is for use solely at work or in education. Please see the resource on our website for advice on computer access in schools.
We provide our referral form in a word document setup as a form to allow it to be completed electronically. Please contact us if you require the form in any other format.
Sending the form
Before you send the referral please contact us if you are unsure about any of the above.
Please email this form to our team address: email@example.com.
If you are sending from another nhs.net email address this is secure as is sending from gov.uk and some other domains. Alternatively you can send the referral as an encrypted (256bit minimum) document. In all cases, please ensure you are complying with your organisation’s information governance and data protection procedures when sending this form.