Virtual Reality Treatment Referral Form :: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

Referral Criteria

Referrals accepted from GPs, Child and Adolescent Mental Health or Paediatric/Child Health Services

Referrals can only be considered following receipt of this form and the relevant information
Young people must have a specific phobia (i.e. a marked fear or anxiety about a specific object or situation that impacts on functioning)
The young person must have an Autism Spectrum Disorder, be aged 7-17 years inclusive, and be able to use and understand sentence speech at the time of referral
There is a cost of £3500.00 for the virtual reality treatment which must be funded locally
Referral must include:
- Information about the young person’s situation specific phobia to be targeted
- Information about the local Clinical Commissioning Group or other proposed funding source so they can be approached for funding, or confirmation that funding has been secured
- Details of clinical team retaining clinical responsibility for all other health/mental health needs

Child or Young Person's Essential Details

This section must be fully completed for all referrals

Name Required

Date of Birth Required

Age Required

Preferred Pronouns Required

If other, please specify

Preferred first name Required

Birth Assigned Gender Required

Current Gender Indentity Required

Address Required

Address 1

Address 2

City

Country

County

Postal Code

Telephone Number Required

NHS Number Required

RiO Number (if applicable)

Ethnicity Required

GP Details (name, contact details including postcode) Required

Please let us know whether funding for the treatment has been agreed? Required

If Yes, please give funding source name and address

If No, please give Clinical Commissioning Group or other funding source name and address

Legal status - Looked After Child Required

If Yes, please idicate:

Section 20 accommodated

Interim Care Order

Full Care Order

Section 25

Legal status - Mental Health Act Required

If Yes, please provide details

Name & Address of person(s) holding parental responsibility Required

Telephone Number (if different to Young Person)

Referral Details

Job Title Required

Referrer name Required

Referrer address Required

Address 1

Address 2

City

Country

County

Postal Code

Referrer telephone number Required

Referrer fax number

Name and contact details of Lead Clinician or Care Co-ordinator Required

Team Confidential Email Contact Required

Referral Date Required

Details about situation specific anxiety, phobia/fear (please be as specific as possible about the specific situation that provokes anxiety, frequency of occurrence, impact on the child and family) Required

Details of any previous treatment for anxiety, phobia/fear Required

Current diagnosis/formulation Required

Current medications Required

Any risks to be aware of Required

If Yes, please provide details

Additional background information (Please include any relevant family history including neurodevelopmental disorders/psychiatric disorders, details of any educational supports etc) Required

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Virtual Reality Treatment Referral Form

Referral Criteria

Child or Young Person's Essential Details

Referral Details

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