Download Referral form for doctors and agencies

The Planetary Healing Centre
Referral Guidelines and form for Health Professionals
The following are the services offered by our charity. Depending on the aims
of the service there are specific entry criteria that are required. If you need
more details please call our office on 0131 449 4467.
HOLISTIC HEALTH PROJECT: Eligibility
1. Complementary Therapies by contribution for people who are struggling
financially and affected by ill-health, including mental health issues,
struggling to come to terms with diagnosis, struggling with the physical,
mental and emotional effects of living with a life threatening condition,
people who are homeless or at risk of becoming homeless and people
hoping to cope better, gain more control of their health and wellbeing, build
confidence to move on in life in more effective ways.
Referral to the project can be done by Health Professionals. Individual clients
can also self- refer by calling us to book and by filling in an application form
to register in our project.
NATURE CONNECTION FOR FAMILIES: Eligibility
1. Outdoors Nature programme for families experiencing the same as above.
(Children accompanied by parent or guardian). Physical outdoors exercises
has a well-documented, positive effect on health, wellbeing and resilience to
stress. Our project helps reduce the symptoms and effects of ill-health and or
stress as well as improves family relationships. The children work outdoors
alongside their parents/carers, planting, nurturing, and learning about nature.
Please indicate which project service you are referring to:
HOLISTIC HEALTH PROJECT
NATURE CONNECTION FOR FAMILIES
A. Referring Person
Name
Post
Organisation
Address
Post code
Telephone No:
Email:
B. Client’s Details
Full Name
Date of Birth Age:
Male
Female
Transgender
Address
Post Code
Telephone:
Email:
Ethnic Group Main Language:
Occupation:
Client’s emergency contact (family member or close friend name and tel):
C. Main Carer’s Details
Name Relationship:
Telephone:
D. GP Details
Name
Address
Post Code:
Telephone:
E. Other Professionals Involved. Please tick all that apply and give details:
Name
District Nurse
Hospice nurse
Other Specialist nurse
Other:
F. Reasons for Referral and main focus of work for the client.
Please give as much information as possible to help us with our assessment. In
particular, we would need to know about current conditions and
medications that may present contra-indications.
G. Main Symptoms
Please tick all that apply:
Pain
Anorexia
Weakness
Confusion
Dyspnoea/Shortness of Breath
Difficulty sleeping
Lack of energy/fatigue
Dysphagia
Anxiety
Suicidal
Depression
Skin conditions
Other:
Details of patient’s current therapeutic and psychological care needs:
Please give a brief description of the client’s level of mobility:
Independently mobile
Uses Wheelchair
Other:
H. Allergies
None known
or
Uses mobility aid Stick
Confined to bed
Frame
If Yes (please give details below)
I. Medication
J. Other important information
Have you included any additional information with this referral? Yes
Signature of Referrer: ____________________________
No
Date: _______________
Please return this form via email and write in subject line confidential to:
Claudia Goncalves: E-mail: [email protected]
If you prefer to post it: Planetary Healing Centre’s registered office:
Cockburnhill Road, Balerno, EH14 7JB.