For Professionals

Professional Referral Form:

This form is for GPs and other professionals - if you wish to refer yourself, please use the Self Referral Form instead. Please note we can't accept referrals made by partners, family members or friends. By completing and submitting this form you are confirming that your client has agreed for their information to be stored on our confidential service database. This information is held securely and is not viewed by anyone outside of Impact on Teesside.

Referrer Details

Client Details

GP Details


Has the client...

Reasons for Referral

Next of Kin Details

Professional Contacts? (Where relevant / neccessary)

Please email any supporting documents including any assessments completed by Secondary Services (e.g. Access Teams or Crisis Teams), otherwise there is a possibility that this referral will be declined. A reference code will be provided on the next page.