Referrer Details

Please note that we do not currently offer Short- Term Placements for our Therapeutic Day Service. If this is something you may require, please speak to us directly.

Service User Details

Date of Birth (please note that the Re-engagement and Therapy Day Services run from ages starting at KS3):

(Please send any supporting documents at the time of referral)

(If ‘Yes’, please send the safety plan with the referral and any other supporting documents)

Please provide a brief educational overview for the service user: (although education isn’t our first priority in these services, it is helpful to have an overview of understanding of academic capacity such as abilities to read and write):

In your opinion, have any specific psychological interventions been helpful in supporting this person? (If yes please list which interventions and the timeline of when they were accessed). 

(Our model provides a combination of Cognitive Behaviour Therapy, Relaxation Therapy, Animal Therapy and Occupational Therapy to suit the needs of the service user and support their wellbeing.)

Clinical Details

Does the service user have a history in any of the following?(Please tick):

The following is in relation to deterioration in the service user’s mental health.

Note: If there are any changes with the service user’s mental health or medication, the referring organisation or caregiver would be required to let us know as soon as possible.

Emergency contact details for the service user:

(We use SMS or telephone calls to keep caregivers up to date on the service user (as required) so please provide a phone number where permission is granted for both SMS and calls during the therapeutic day)

Assessment

Billing Information:

The assessment consists of a digital form which is to be completed prior to us meeting the individual. This is classed as ‘Stage 1’ of our assessment process, followed by ‘Stage 2’ which is a two-day practical assessment for anyone wanting weekly time above three hours on the Re-engagement model. Anything below three hours will be a 30 minute assessment following the digital form. We reserve the right to request a further assessment should we deem it appropriate for specific cases. Please provide contact details for the most relevant person/s to undertake each part of the assessment.

Digital Assessment form: Our preference is for parent or care giver to complete this, as we have an understanding of professionals viewpoint from this form. However, in some cases we know this is not feasible and therefore please list the most relevant adult:

Practical Assessment 

(Maximum two adults; recommended one professional and one caregiver). 

For the two day assessment, the supporting adults will be required for the first 2 hours of the first day assessment. If the service user settles within this time, they will be able to remain on site until the end of the therapeutic day. This allows staff to assess engagement and affirm we can safely meet their needs in the outdoor setting, before meeting them again for the second day. 

Adult 1:

Adult 2:

therapy@adotherapy.co.uk

If you have any questions, please call 0203 6217 684

A member of the team will be in touch with you shortly (office hours 9:00am until 5:00pm)