PHB: referrals

If you have referred this person before and their personal information hasn't changed, please fill in their name and NHS number, then go straight to the referral section. To make a referral to the PHB service you will need to:
- fill in the referral form
- include the service user’s PHB support plan; here is a template if you need it
- have authorisation to make the referral at the appropriate level.
About the referrer
Referrers name
First Last
Phone
Mobile
Email

We'll send you a copy of the information you give on this form to this email address.
Job title
Team*
Professional relationship
- Social worker
- Doctor
- Physiotherapist
- Nurse
- Health professional
- Other
Does another health professional need to know about this referral?
Name - other professional
First Last
Email - other professional

We'll send a copy of the information you give on this form to this email address.
Job title - other professional
Team - other professional
Professional relationship - Other
- Social worker
- Doctor
- Physiotherapist
- Nurse
- Health professional
- Other

About the budget holder
Name
First Last
NHS Number*
Is the budget holder under section 117?
- Yes
Does the budget holder have recourse to public funds?
- Yes
- No
- Unsure
Phone
Mobile
Email
Patients Know Best
- Would you like to register with Patients Know Best (PKB) to have access to your PHB information online?
If you would, you must enter a valid email address above. This will be used in the Patients Know Best registration process.

For more information about PKB take a look at the Patients Know Best leaflet.
Location
Street
City or town
Post code
Borough

Communication
Language spoken
Communication support required or used
Communication professional required
Communication observations
What do we need to know about their communication needs?
Preferred contact method
Preferred information format

Additional information
Using the Personal Health Budget safely
Are there any risks that need to be considered and how will these be managed?
Confirmation
- I, the referrer, have read the guidance around using PHB safely and have discussed this with the person I am referring
PHB Guidance
Additional information
Please tell us anything else you think will help with this referral
Please complete and attach the full PHB support plan
Please make sure you complete all sections.
Please attach the support plan
Max. file size: 98 MB.

Purchases
Please contact the team with questions about payment type
How many product and services would you like to request
The number you select will determine the number of product or service sets of question you see
How will the purchase be made?
Product or service 1
Product /service
Name of the provider
Quantity (number of sessions/products)
Unit cost (cost per session or product)
Total cost of this product or service
Quantity x unit cost
Payment type
Please contact the team with questions about payment type

Approval
£0 – £250 – Approval by assessing Clinician
£250 – £750 – Approval by Team Manager
£750 – £1000 (or greater by exception) – Approval by Team Manager and then sent to the CCG for final budget spend approval.
If the budget is above £250 please complete the information below
Total budget
The total cost of all activity and purchases
Approving manager's name
If required
First Last
Approving manager's phone
Approving manager's email
If the value of the services or products exceeds £250, have you discussed this with your manager?
- Discussed with manager

Permission for us to use this data
- Please check the box if you understand that by submitting this personal information you are consenting to The Advocacy Project holding and using it in accordance with our privacy policy.
Please note we may share this referral information with one of our partner organisations if they are delivering the service you need.
Please see our privacy policy
If you need help or have questions about any aspects of the Personal Health Budget process please contact us:
Phone 020 3869 9728 or
Email HackneyPHB@advocacyproject.org.uk
Email
This field is for validation purposes and should be left unchanged.

About the referrer