Professional Referral Form

Please complete as much information as possible to enable us to process your referral as efficiently as possible. Some fields are mandatory and are marked with an *

We have been and always will be committed to maintaining your right to privacy. The information you provide us with is held securely in line with the General Data Protection Regulations 2018. Please view our Privacy Policy.

  • Professional Referral Form
  • Date Format: DD slash MM slash YYYY
  • Patient Details
  • Date Format: DD slash MM slash YYYY
    Please provide any other clinical information below. This will assist us to ensure that the appropriate clinician is selected to treat the patient. If you have any additional reports or documents that you would like to send to us, you will be able to upload them below.
  • Accepted file types: doc, docx, pdf.
  • Referrer Details
  • If you anticipate a delay between your enquiry and proceeding to an assessment, we would be grateful where possible if you could indicate an approximate start date below.
  • Please upload up to 3 documents that you feel may be relevant here. We accept Word documents (file extension .doc or .docx) and PDF files.
  • Accepted file types: doc, docx, pdf.
  • Accepted file types: doc, docx, pdf.
  • Accepted file types: doc, docx, pdf.
  • Funder Details
  • Please tell us who will be responsible for authorising us to proceed with your instruction and for payment of our invoices.
  • Fee Structure

    • Please be advised that our travel costs are based on the suggested travel time of a route planner at £40.00 per hour and £0.55 per mile.
    • Should the situation arise whereby more than one patient is treated by the same therapist on the same day and in the same local geographical area, a travel cost reduction may be applied. Any reduction in travel costs will be clearly identified on our invoice as a 'Special Travel Rate Reduction'.
    • Our Treatment Plans are charged at the Therapist time rate of £80.00 per hour up to a maximum 2.5 hours.
    • Our Personal Management Programmes are a photographic training tool, specific to the patient, to be used as and when needed and are charged at £80.00 per hour up to a maximum of 2.5 hours.
    • We would like to take this opportunity to advise you of our cancellation policy. 24 hours notice is required for cancellation of a session. If less than 24 hours notice is give, please note that other than in excepting circumstances, the full session rate will apply. Please support us to ensure chargeable cancellations are kept to a minimum by ensuring all staff and family involved are aware of their responsibilities to communicate cancellations as soon as practical.
    • Invoicing is on a month end basis and our payment terms are 14 days.
    • Further information regarding our payment terms along with our Terms and Conditions can be found at Our Policies
  • Administrative Controls
  • This field is for validation purposes and should be left unchanged.

Important note:
If you have completed the form successfully, once you click Submit, you will be redirected to a ‘thank you’ page. If you have missed out the required information, this page will reload and you must scroll down and correct any omissions before submitting the form again. If you do not do this, all your information will be lost!

We can provide home visits & clinic appointments.

SP Therapy Services take great care in providing an exceptional standard of therapy to all our patients, whatever their individual age, diagnosis or location.

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