Referral Form - SELFA Children's Charity Skipton

Complete this form in full, giving the reason for referral. Providing full information helps us give appropriate support and gauge level of need.

This field is hidden when viewing the form

Family Name

Name(Required)

Enter name of child/young person

Address(Required)

Street Address City/Town Postcode

Enter address of child/young person

Date of Birth(Required)

Gender(Required)

Ethnicity(Required)

School Name(Required)

Are you the parent/carer of the child?(Required)

Yes

No

Name of person making this referral(Required)

Prefix First Last

Job title(Required)

Organisation(Required)

Mobile

Work tel

Address

Street Address City ZIP / Postal Code

Email(Required)

Details of agencies involved

(e.g. CAMHS, Social Work, EMS, Carers’ Resource, Early Help Service, Health Visitor etc.) – include name of worker

Please select all issues applying to the child/young person

Hold the Control key to select more than one choice

Reason for referral and background information(Required)

(including methods/techniques already in place to support the child)

Child has one-to-one support in school(Required)

Yes

No

SELFA needs to carry out a risk assessment to keep this child, adults and other children safe(Required)

Yes

No

If yes, what are the issues we need to be aware of? Do they have an individual Risk Assessment?(Required)

(please provide Individual Risk Assessment if available)

Please upload any relevant Care or Behaviour Plans, EHCP and Risk Assessments

Drop files here or

Max. file size: 50 MB.

The remaining information needs to be completed by the Parent/Carer. If you are completing this form with them, please click Next. Alternatively, click Save Progress. You can then request an emailed link which can be forwarded to the Parent/Carer for them to complete the form.

Primary Parent/Carer(Required)

First Last

Relationship to child(Required)

Date of Birth(Required)

Parent/carer’s date of birth

Gender(Required)

Parent/carer’s gender

Ethnicity(Required)

Parent/carer’s ethnicity

Home Telephone Number

Work Telephone Number

Mobile Phone Number(Required)

Email(Required)

We often use email to contact parents & carers with information on activities and other important updates. Please provide an address where we can contact the parent/carer

This parent/carer lives at the same address as the child(Required)

Yes

No

This parent/carer has parental responsibility(Required)

Yes

No

Does another parent/carer have responsibility for the child?(Required)

Yes

No

Second Parent/Carer Name(Required)

First Last

Relationship to child(Required)

Date of Birth(Required)

Parent/carer’s date of birth

Gender(Required)

Parent/carer’s gender

Ethnicity(Required)

Parent/carer’s ethnicity

Home Telephone Number

Work Telephone Number

Mobile Phone Number(Required)

Email

We often use email to contact parents & carers with information on activities and other important updates. Please provide an address where we can contact the parent/carer

This parent/carer has parental responsibility(Required)

Yes

No

This parent/carer lives at the same address as the child(Required)

Yes

No

This field is hidden when viewing the form

This parent/carer has parental responsibility

Yes

No

This field is hidden when viewing the form

This parent/carer lives at the same address as the child

Yes

No

Emergency contact (someone other than parents/carer entered above)(Required)

Please provide details of someone we can contact in an emergency if we cannot get through to a parent/carer

Relationship to child/family(Required)

Telephone number(Required)

Please enter the best number to contact this person on

Other people with permission to collect from activities

Doctor

Surgery(Required)

NHS Number

Medical conditions

Please include details of medication where relevant.

Does the child have allergies(Required)

Yes

No

Please provide details(Required)

Please give details of any allergies your child has – you can also include suitable substitutes where relevant.

Does the child have other special dietary requirements (e.g. vegan, vegetarian, halal, kosher)(Required)

Yes

No

Please provide details(Required)

Please give details of special dietary requirements

Child has an EHCP(Required)

Yes

No

Child is eligible for free school meals(Required)

Yes

No

To be completed by the parent/carer

I give permission for my child to be photographed/videoed for display purposes/promotional materials including our website, brochures and the local press(Required)

Yes

No

I give permission for my child to have first aid administered in the event of an accident/injury(Required)

Yes

No

I give permission for my child to go on trips accompanied by SELFA staff(Required)

Yes

No

Please upload a Pen Picture completed by/with the child.(Required)

Max. file size: 5 MB.

A blank Pen Picture can be downloaded here.

Please upload any relevant Care or Behaviour Plans, EHCP and Risk Assessments

Drop files here or

Max. file size: 50 MB.

SELFA takes the handling of personal data extremely seriously. Please read our Privacy Notice below for further information.

Privacy Notice (opens in a new tab)

Service User Privacy Notice(Required)

I consent to the use of my/my child’s personal data as described in the Privacy Notice