Before
you refer.
The referral said I had “poor engagement”. My bus doesn’t run on Tuesdays.
A five-minute guide for GPs, social workers and other professionals referring a disabled person for therapy.
What this is: a short guide to writing a referral that starts therapy in the right place.
Why it matters: the referral often sets the goal before the person has spoken.
The sharpest reframe: describe what’s happening; don’t label it.
One thing to take away: ask the person first, and use their words.
The short version
A referral letter often decides what therapy will be about before the person has said a word. Before you refer a disabled person for therapy, ask them what they want help with, describe what’s happening in plain, specific words rather than labels like “difficulty accepting disability”, and pass on their access needs with their agreement. Check whether some of the problem needs action elsewhere, such as care, housing or work, alongside or instead of therapy. Two minutes spent on these makes it far more likely the therapy starts in the right place.
You might recognise this
Illustrative statementsDrawn together from common experiences. They are not quotes from individual people.
Who this is for
GPs, social workers, occupational therapists, physiotherapists, rehabilitation and disability service staff, and anyone else who refers disabled people to counselling or psychotherapy. It’s written to take about five minutes.
1. Ask the person first
Our framework- Do they want therapy? Being referred when you didn’t ask can feel like being told the problem is in your head.
- What would they like help with? Use their words in the referral. More on this on Whose Goal Is It?
- What do they want the therapist to know, and what do they want kept out of the letter?
- How do they want to be contacted? Letters, phone, text, email, or through someone else.
2. Describe, don’t label
Our frameworkSome common phrases set a goal the person may not share, or read a practical problem as a psychological one.
Instead of
“Difficulty accepting disability”
Try
Wants help with [what they named], e.g. returning to work after their diagnosis.
Acceptance may or may not be their goal. Let them say.
Instead of
“Poor engagement / did not attend”
Try
Missed three appointments; reports unreliable accessible transport and fatigue after travelling.
Missed sessions often have access reasons.
Instead of
“Unrealistic expectations about recovery”
Try
Hopes to regain more mobility, and would like support with uncertainty about whether that will happen.
Wanting improvement is legitimate.
Instead of
“Challenging behaviour”
Try
Becomes distressed and shouts when [specific situation]; this started after [change].
Describe what happens, when, and what changed.
Instead of
“Low motivation”
Try
Has stopped [activities]; also has significant fatigue from [condition].
Fatigue, pain and medication can look like low mood or motivation.
3. Watch for diagnostic overshadowing
Established conceptDiagnostic overshadowing describes how an existing disability can lead professionals to attribute new emotional or behavioural difficulties to that disability, so that a treatable mental health difficulty goes unassessed. The term was introduced by Reiss, Levitan and Szyszko in 1982, in work with people with intellectual disabilities. It can also run the other way: a physical cause for a change, such as pain, infection or medication, can be missed if the change is read as purely psychological.
More on Assessment Bias and Diagnostic Overshadowing.
4. Pass on access needs, with permission
Our frameworkWith the person’s agreement, include what they need to take part. For example:
Communication
Sign language, lip-reading, captions, communication aids, plain language, time to respond, aphasia.
Getting there
Step-free access, parking, accessible transport and how reliable it is, or a preference for online sessions.
Energy and timing
Best time of day, session length, fatigue or pain patterns, fluctuating conditions.
Information
Preferred format for letters and forms: large print, easy read, email, audio.
Support
Whether they’d like someone with them, and who. Only with their agreement.
Don’t assume what someone needs from their diagnosis. Ask.
5. Is therapy the right thing, or the only thing?
Our frameworkSome distress is a reasonable response to a situation that needs changing: an unreliable care package, an inaccessible home, discrimination at work, money worries. Therapy can help someone cope and decide what to do, but it can’t fix these. Consider whether a referral for advocacy, social care, occupational therapy, benefits advice or legal support is needed alongside therapy, or instead of it.
Ultán is 47 and had a stroke eight months ago. His GP’s first draft of a referral said: “Low mood and difficulty accepting disability following CVA. Poor engagement with rehab.”
Before sending it, the GP asked Ultán what he wanted. He said he was frustrated that he couldn’t follow conversations at family dinners, and he’d missed physio because the hospital car park had no free accessible spaces after 9am. The revised referral read: “Low mood since stroke. Wants help with frustration and isolation at family gatherings, where he struggles to follow fast group conversation. Has mild aphasia: please speak slowly and allow time to respond. Prefers morning appointments; parking is a barrier, so online sessions may suit. Has missed physiotherapy because of parking, not lack of interest.”
Ultán is a fictional teaching example, not a real person.
Before you send it
- Have I asked the person what they want from therapy, and used their words?
- Have I described what’s happening, rather than labelling it?
- Have I included their access needs, with their agreement?
- Have I checked whether a physical cause, or a practical problem, explains some of this?
- Have I considered other referrals alongside therapy?
- Does the person know what’s in the letter, and who will see it?
Evidence & sources
Sources checked in October 2026, using targeted searches rather than a systematic review. “We have not located” means our searches did not find it.
Diagnostic overshadowing: Reiss, S., Levitan, G. W. & Szyszko, J. (1982), in research on people with intellectual disabilities. See “Diagnostic overshadowing”, in The SAGE Encyclopedia of Intellectual and Developmental Disorders (2018), doi:10.4135/9781483392271.n130.
United Nations (2006), Convention on the Rights of Persons with Disabilities, Article 9 (Accessibility) and Article 25 (Health).
The wording alternatives, the access headings and the checklist are this site’s synthesis.
Ultán and his referral are constructed for learning. He is not a real person.
Our targeted searches did not find research on how referral wording affects therapy for disabled people.
How to cite this page: Donaghey, C. (2026). Before You Refer. Disability in Psychotherapy. Available at: https://disabilityinpsychotherapy.online/for-referrers-and-services/before-you-refer/ (Accessed: [date]).
Shared under CC BY-NC 4.0, with an extra permission to teach from it on fee-paying courses. Credit the site. See Reusing This Material.