Referral form

Please complete the relevant form in confidence.

We will get back to you as soon as possible to discuss a planned approach under the guidance of Koru.

Referral Guidance:
Can a young person be referred to KORU for therapy if they are already receiving therapy from another source?
• No, because it becomes very confusing for the young person. It is only in rare circumstances that exceptions may be made.
• No, because it is also a waste of resources
Referrer, agency, address and telephone:
Name
First Last
Agency
Professional body
CAMHS, Social Services etc
Address*
Street Address Address Line 2 City City / County Postal Code Country
Phone*
Email*
Enter Email Confirm Email
Date*
Date Format: DD slash MM slash YYYY
Young Person Referred*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Parent(s) or main carer’s name*
First Last
Address*
Street Address Address Line 2 City County Postal Code Country
Phone*
Email
Enter Email Confirm Email
School and Name of Key Worker
School
First
Key Worker*
First Last
Address*
Street Address Address Line 2 City County Postal Code Country
Phone*
Email*
Enter Email Confirm Email
Referral Information*
Name of referrer*
First Last
Name & details of funding source
Who is funding this application. Who shall we be invoicing?
Name*
First
Email*
Phone*
Address*
Street Address Address Line 2 City County Postal Code Country
Please note funding is paid in full before the start of the therapy. No refunds can be reimbursed but sessions cancelled with more than 48 hours notice can be passed on for work with other children and young people.
Date*
Date Format: DD slash MM slash YYYY

Save and Continue Later

Referral Guidance: