Lamplight API response

First name

Last name

Address 1

Address 2

Address 3

Address 4

Address 5

Postcode

Email address

Mobile phone

Phone number

When we contact you about your child's referral, what is the best way to get in touch. Please tick your preferred methods and also if you would like to hear from us via our newsletters and email.

By post

By email

By mobile

By text message

Other information

Main Parent/carer name

Does the main parent/carer have parental responsibility?

Child's Information

D.O.B

Gender

Ethnicity

Preferred Language

Is the Child Adopted, subject to SGO (Special Guardian Order) or LAC (Looked After Child)

Is the Client a Young Carer?

Is the child subject to a Child Protection Plan or Child in Need Plan?

Is the child subject to court proceedings

If yes- Please provide brief details

Child's School Details

School

School Postcode

If Other School: please provide name and address

School Contact's name

School Contact's telephone number

School Contact's email

Family Details

Name of other Parent/Carer

Does this parent/carer have parental responsibility?

Does this parent/carer reside with Child?

Address of other Parent/Carer (If they do not Reside with Child)

Contact number of other Parent/Carer

Referral Information

Therapy being referred for

Please provide a brief overview of why the child is being referred

Reasons for Referral

How long have you been trying to obtain support for the child being referred?

Preference for delivery of therapy services

If Hub (please indicate preferred timings)

Is the referral Professional or Parent/Carer?

Name of Referrer (if not parent/carer)

Referrer Position (if not parent/carer)

Referrer Contact Number (if not parent/carer)

Referrer Email (if not parent/carer)

Please confirm if the parent/ carer is aware of this referral

Therapy Services Funding

As a small charity, we are working hard to make our services accessible to all. We have limited numbers of free and subsidised places for therapy services which are allocated on a needs basis. Individual circumstances will be considered.

Any discounts may be related to income related benefits or other factors which may affect ability to pay. However please be aware that this is not guaranteed and this can impact waiting times.

If you would like to be considered for bursary funded support, please indicate below and we will be happy to discuss this further with you.

How will this therapy be funded?