Referral Form

PRIVACY & CONFIDENTIALITYPlease fill out the below referral form

The privacy and confidentiality of all families are of my upmost importance. Please fill out the below form with as much detail and accuracy as possible.

I will attempt to get back to you within 3 working days.

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Referral Form

1. Name of Referring Agent: *

2. Service: *

3. Agent Contact Number: *

4. Agent Email: *

5. Name of Parent/Carer: *

6. Home Address: *

7. Parent/Carer Contact Number *

8. Parent/Carer Email Address: *

9. Please enter the Name, Date of Birth and Nursery or School for all Children

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

Child 7

Child 8

10. Name of Parent/Carer who is in agreement with this referral:

11. Print today's date

12a. Are the family open to statutory Services

12b. Name of Social Worker:

12c: Social Workers contact number

13a. Are the family open to Children First/Early Help :

13b. Name of the allocated worker:

13c: Allocated Workers contact number

14a. Does one of the children have an EHCP :

14b. Name of Child:

15a. Are the children open to or on the waiting list for CAMHS or engaged with a similar service:

15b. Name of referred child:

16. Details for reason of referral and presenting problems (severity, duration and impact) and any information relevant to the referral:

17. What are the child’s strengths and weaknesses?

18. What programmes/support have been accessed previously in relation to the concerns? And what was the outcome?

19. What is the child’s voice?

Call me now on 07599 674 044 or email me at felia@kidzhope.co.uk and schedule your first FREE 10-minute friendly phone consultation. I am also happy to answer your queries via SMS and email. Should I be unavailable, please leave a message, and I will get back to you as soon as possible.

I am based in Slough, Berkshire and currently operate in Slough and nearby areas within 20 miles.