Self-Referral General Preferred * Assessment Session for Free Funding Self-Paid & Assessment Session (Free Funding) Self-Paid only Employment Support OtherOther How would you like to be contacted? Email Text Phone OtherOther How did you find us? Internet Search Social Media Recommendation MS-UK Scope Amputation Foundation Other Other Your Referral Disability or Injury? Autism Brittle Bones Brain Injury BSL Counselling England BSL Counselling Wales & Scotland BSL Counselling Ireland Ehlers-Danlos Syndrome Endometriosis Cerebral Palsy Downs Syndrome Hearing Loss Muscular Dystrophy Continued Limb Loss Lumber Spondylosis Multiple Sclerosis Rare Genetic Disorders Road Traffic Accident Skeletal Dysplasia Spina Bifida Spinal Cord Injury Sight Loss Other The NHS ASD DisabilityPlus are not able to apply for Free Funding. Visit your General Practice, they can refer you to specialist NHS Funded ASD service . The NHS BSL DisabilityPlus are not able to apply for Free Funding in Ireland. Please visit your GP for mental health counselling. The NHS BSL DisabilityPlus are not able to apply for Free Funding in England. SignHealth have a national contract with NHS England. Their website:https://signhealth.org.uk/with-deaf-people/psychological-therapy/ Road Traffic Accidents DisabilityPlus are not able to apply for Free Funding if you have NOT obtained a disability through the accident. Issue's Counselling Topics Adjustment Disorder Anxiety Autism Chronic Pain Depression Chronic Fatigue Eating Problems Grief Low Self-Esteem Life-Changes Mood Swings PTSD Social Anxiety Other Other? Address & Contact Your Name? PostCode? Date of Birth 00/00/0000 Phone Number? Email * Gender? Summary Brief Summary? If you are human, leave this field blank. Submit Self-Referral Form Self-Referral Form General Choice of plan * Assessment Session for Free Funding Self-Paid & Free Funding Application Self-Paid only Employment Support OtherOther How do you find us? Internet Search Social Media Recommendation MS-UK Scope Amputation Foundation Other Other Reply to you Email Text Telephone Any Your Referral Checkboxes Ataxia Autism Brain Injury Deaf Cerebral Palsy Limb Loss Muscular Dystrophy MS Spina Bifida Spinal Cord Injury OtherOther Therapy Topics? Issues? Adjustment Disorders Anxiety Chronic Pain Depression Chronic Fatigue Eating Problems Low Self-Esteem Life Changes Mood Swings PTSD Social Anxiety OtherOther Address & Contact Your name? Postcode? Date of birth 00/00/0000 Phone number? Email * Your gender? What you would like to be referred to as? Anything to add? Can write anything in here. If you are human, leave this field blank. Submit
