Cup-O-T: Wellness and Therapy Services - Therapy Referral Form
Please complete the referral form below as fully as possible to help us triage.  Our team triages referrals twice a month and you will be emailed with the outcome from that meeting.
If you are enquiring about a funded therapy space there may be a wait until a practitioner has availability or funding is available.  Further information about the therapy and groups we offer can be found on our website: https://www.Cup-O-T.co.uk 
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Referrer information - Email address: *
Referrer information - Name: *
Parent/Carer- Email address: *
Parent/Carer - Name: *
Parent/Carer telephone number *
Client Details
Please fill this in about the person who wishes to receive therapy. If under 16 we require a parent/Guardian's name and contact information before we can proceed.
Have you informed the young person that they have been referred so they know what to expect? *
Full name of person being referred *
Date of Birth *
MM
/
DD
/
YYYY
Home address *
GP's name and address *
Are you referring from a partner organisation (selected which) or enquiring about a funded space? *
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