Hackney Family Backup

Providing Community Support and Social Inclusion for Disabled Children and Young People

Referral Form - Family Support Services

Community based links for children / young people (0-17) with disabilities and / or complex health needs

Please ensure that all the form is completed because we have a range of services. This helps us work out family support needs, and match families to helpful services.

If you prefer to apply by post, please print, complete and return this referral form.

Parent / Main carer name:
Address:
Postcode:
*Please give at least one telephone number:*
Home telephone:
Work telephone:
Mobile telephone:

Please tell us about all the children in the family aged 0-17.

Child's name	DOB	Gender	Religion	Ethnic origin	Languages	Disability

Who is making this referral?
Parent / main carer Child / young person Other

If other, please give details:

Referrer's name:
Referrer's address
Referrer's contact number:

Does the child / young person and family know about the referral?
Yes No

Which services would you be interested in? (Tick as many as you like)
Big events, parties and outings
Smaller, targetted outings
Family club
Family support volunteers
Parent workshops / coffee mornings / events

Please tell us more about the children in the family who have disabilities and/or complex health needs:

Does the child / young person have any health or medical needs? Are there any health professionals working with the child? Tell us more:

Does the child have any challenging behaviour or social issues? Please tell us more.

Tell us about the child / young person's support needs in any other areas, e.g. language and communication, self-care, physical needs, social skills:

Please tell us why this referral is being made at this time:

Are there particular stresses the family is experiencing at the moment?

Is an interpreter required for an assessment visit?
Yes No

If yes, in which language?

The information on this form will be held and processed by Hackney Family Backup in written and/or computerised records, within confidentiality and data protection policies, for the purpose of service provision and monitoring.

©2010 HFBU - Registered Charity No: 1017015 - Company Registration No: 2422896
HFBU never make direct appeals to the public for funding. If you receive an e-mail requesting
financial assistance that you think might be from us please contact us immediately.