Hackney Family Backup

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

Referral Form - Respite Care / Homesitting

Community based links for children / young people (0-19) with disabilities and / or complex health needs

Please ensure that all sections of the form are completed in full. This is essential for prioritising referrals, and in order to match children with appropriate carers. Please also send us the child's most recent needs assessment form where possible (this page gives our contact details).

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

All fields marked with an asterisk * are compulsory.

Child / Young person:*
Address:*
Child / YP's DOB:*
Child / YP's ethnic origin:*
Child / YP's religion:*
Child / YP's gender:*	Male Female
Family's first language:
Other languages spoken:
Parent / Main carer name:*
*Please give at least one telephone number*
Home telephone:
Work telephone:
Mobile telephone:
Date of referral:*
Referrer's name:*
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?*

Does the child / young person go to college / school / nursery?
Residential Day

School / College / Nursery address:

Postcode: Tel no:

Outline of child / young person's needs, e.g. health, language and communication skills, self-care, mobility and other physical needs, emotional and behavioural development, social skills.*

Please specify any particular matching considerations, e.g. particular cultural, religious or language needs, or particular skills required of the respite carer, e.g. communication skills such as Makaton, BLISS, BSL, ability to tube feed etc.*

Please specify any particular times or patterns of care needed, including whether the family prefers homesitting in their own home, or respite at a carer's home.*

Why is this referral being made at this time, and are there particular aims for respite, e.g. to prevent family breakdown, to alleviate sleep deprivation, to support children's development in particular areas etc?*

Does this child meet Hackney's eligibility criteria for overnight respite?*
Yes No

Is lifting and handling assessment required?*
Yes No

Is an interpreter required for an assessment visit?*
Yes No

If yes, in which language?

©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.