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About Us
Services
- Rapid Support
Referrals
Contact Us
Call Us
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Referral Form

NB-All fields are mandatory in order to process the referral.

Child Information

Child Name

DOB *

Phone *

Street Address *

Apartment, suite, etc

City

Post Code

Country

Email Address

Gender At Birth *MaleFemale

Ethnicity *White BritishOther WhiteWhite Gypsy or Irish TravellerBritish AsiansIrish peopleBlack

Religion *ChristianityIslamHinduismSikhismJudaismBuddhismOther

GP Information

GP Name *

Street Address *

City

Post Code

Phone *

Email Address

School Information

School Name *

Phone *

Street Address *

City

Post Code

Country

Email Address

Names of those who hold Parental Responsibility

Please provide parental contact details if different from the child/young person:

Prefix

First Name

Middle Name

Last Name

Street Address

Apartment, suite, etc

City

Post Code

Country

Phone

Email Address

Referrer Information

Organization Name

Referred by: *

Please state your job title *

Phone *

Street Address

Apartment, suite, etc

City

Post Code

Country

Signature

Upload Signature

No file chosen

Consent to Referral

Have you discussed this referral with the family/young person? *YesNo

Is the family/young person willing to attend PALMS? *YesNo

Does the family/young person consent to the PALMS contacting the professionals involved prior to meeting us if appropriate? *YesNo

1) Please detail your involvement with the child/young person and in what capacity you will continue to be involved. Please indicate if you are requesting joint work. *

2) Please provide current evidence of whether the child/young person has a global learning disability and/or an autistic spectrum disorder (as defined by PALMS eligibility criteria). *

3) Describe the child/young person’s needs that you are requesting support for (e.g. toileting, feeding, sleeping, behaviour and/or mental health difficulties). *

4) Specify how each need identified above presents at home, school, and in other settings. *

5) Specify how long the difficulties have been identified (example: weeks, months, years). *

Describe the impact of these needs on the child/young person and family. *

6) The interventions and services already accessed and how the needs are currently managed. *

7) Please provide any further details you believe to be pertinent to the referral. *

8) Please specify if the child/young person is on a statutory plan to the LA *

9) Please specify any risk concerns including information pertinent to PALMS undertaking home visits: *

Please list any documentation you have attached to the referral: *

THANK YOU FOR COMPLETING THE FORM

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