INS (Integrated Neurological Services)

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Website Predefined Role
This section will be Hidden in the Live version of the form.
The Role may be predefined by the HTML link to this Web Form to force the role of the user. It may be:
Client - the user is client with a condition
Carer - the user is a carer referring themself
CarerX - the user is a carer referring someone else
Professional - the user is a Healthcare Professional
Referrer - the user is not a carer and is referring someone else
NoConsent - the user does not have consent
None - no referral
INS will hold, process and share information and data provided in this form with other health and social care professionals, such as GPs involved in the treatment. Please see our Privacy Notice for information on how we process data. Thank you.





Professional Referrer Notice
Integrated Neurological Services (INS) is a charity and not an NHS service.

If your client requires NHS community rehabilitation please refer to:
To be eligible for INS services a client must already have a confirmed neurological diagnosis - INS cannot provide diagnostic or medical advice.

INS does not provide long-term therapy at home, but we may arrange an assessment visit to client's home.

INS supports Richmond and Hounslow residents only.

Services provided by INS to those with neurological condition, and their carers:
  • short blocks of one-to-one therapy
  • counselling
  • exercise
  • symptom management
  • creative and peer support groups
Consent should be sought from the client for a referral to be made. If this is not possible a best interest referral should be noted.
Referrer Contact Information













Referrer Address




Carer Contact Information











(NHS number should be in this format e.g 000 000 0000)

INS is a charity supporting adults with neurological conditions. Alternative help may be available for under 18s. Please contact your GP, health authority, local council or other charities for advice. If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000



INS is a charity supporting adults with neurological conditions. Alternative help may be available for under 18s. Please contact your GP, health authority, local council or other charities for advice. If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000

Carer Address






Carer Additional  Details

Emergency Contact consent


If you select No so, We will request this information at assessment.
Emergency Contact







Health & Social Care Professionals involved 







Reason for referral 


Demographics
INS collect demographic data for the purpose of monitoring the diversity and equality of our service users. We only access your personal information for the requirements of reporting to grant making bodies, NHS and local authorities who require this information to ensure equality and diversity of access to our services. Data is shared in a way that you cannot be identified. We do not share or sell data to commercial organisations. Please note this part of the referral is not mandatory. 

Please select the relevant answers:







Client Contact Information











(NHS number should be in this format e.g 000 000 0000)

INS is a charity supporting adults with neurological conditions. Alternative help may be available for under 18s. Please contact your GP, health authority, local council or other charities for advice. If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000
Client Address






If you select No so, We will request this information at assessment.
Emergency Contact







Health & Social Care Professionals involved 





Service Involvement




 If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000

INS needs the consent of the person you wish to refer to proceed further. Please contact INS on 020 8755 4000 or email admin@ins.org.uk for advice.

INS is a charity supporting people with neurological conditions. Alternative help may be available. Please contact your GP, health authority, local council or other charities for advice.

If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000

NEUROLOGICAL CONDITION(S) and details of any other long-term conditions





Reason for referral 


Communication



Travel


Demographics

INS collect demographic data for the purpose of monitoring the diversity and equality of our service users. We only access your personal information for the requirements of reporting to grant making bodies, NHS and local authorities who require this information to ensure equality and diversity of access to our services. Data is shared in a way that you cannot be identified. We do not share or sell data to commercial organisations. Please note this part of the referral is not mandatory. 

Please select the relevant answers:







 If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000


Client Information












(NHS number should be in this format e.g 000 000 0000)

INS is a charity supporting adults with neurological conditions. Alternative help may be available for under 18s. Please contact your GP, health authority, local council or other charities for advice. If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000
Client Address




Emergency Contact consent


Emergency Contact







Health & Social Care Professionals involved





Service Involvement




NEUROLOGICAL CONDITION(S) and details of any other long-term conditions





Reason for referral 


Communication



Safety/Safeguarding



Travel


Carer Contact Details












(NHS number should be in this format e.g 000 000 0000)

INS is a charity supporting adults with neurological conditions. Alternative help may be available for under 18s. Please contact your GP, health authority, local council or other charities for advice. If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000

Carer Address




Emergency Contact consent


Emergency Contact







Health & Social Care Professionals involved







Reason for referral 


 If you have any questions, please contact INS at admin@ins.org.uk or telephone 020 8755 4000


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