1 Start 2 Complete PSU Referral Form Please read before completing this form The Professional Support Unit (PSU) is now able to accept referrals from senior educators who are concerned about those exceptional trainees who have not self-referred to us, for whatever reason, despite signposting and encouragement. We continue to prefer self- referral wherever possible, as this is in keeping with the principles adult education and trainees taking responsibility for their own learning. The form below is for the use of Heads of School and TPDs to make a referral in situations where there is significant concern and every effort has been made to encourage self-referral without success. The PSU will let the referrer know the outcome of the referral, and share more detailed information with the approval of the trainee. We hope that this mechanism will be useful in these rare circumstances, and we will monitor the process and report in due course on how effectively it is working. Name of Referrer * Email Address * Referrer's GMC number (for ID purposes) * Role of Referrer * - Select -Head of SchoolTPDFSDFSD ManagerFTPD at TrustEducational SupervisorDME or Clinical TutorOther (please specify) If Other, please state * Date of Referral * Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year20222023202420252026 Year Trainee's First Name * Trainee's Last Name * Trainee's Email Address (with trainee’s permission) * Level/Grade of Trainee * - Select -FY1FY2ST1ST2ST3ST4ST5ST6ST7ST8VT Issues to be addressed * CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Submit