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 (0-19) with disabilities and / or complex health needs

Please ensure that all the form is completed in full 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.

All fields marked with an asterisk * are compulsory.

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 0-19.

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

Does the child / young person use other services or community resources, e.g. after school clubs, play centres, church groups? If so, where and when?

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? Tell us more:

Are there any health professionals working with the child?

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

Are there particular kinds of support needed, e.g. help to attend hospital appointments or to access local community and leisure resources, play support at home?

Are there particular times when support would be helpful?

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.

©2007 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.