Referral Form About you Have you had a discovery call or spoken to a member of our team? YesNo We recommend speaking with us prior to making a referral. If you wish to speak with us first, please book a discovery call or email us. Discovery Call Email us Name Phone Email Address How should we contact you? —Please choose an option—PhoneEmail Are there any times that are inconvenient for us to contact you?* Who is this referral for?* Home language* Does the person you're referring (or yourself) require an interpreter?* —Please choose an option—NoYes Does the person being referred (or yourself) require any adjustments?* The person being referred If you are referring somebody else, please provide their details here. If you are referring yourself please answer 'n/a'. Name of the person you are referring Their address (if different) Their Date of Birth Your relationship status to the person —Please choose an option—Familyn/a Parental responsibility for this person (if under 18 years)?* —Please choose an option—NoYes Do you have the permission of the person with parental responsibility to make this referral? —Please choose an option—NoYes Please note, we cannot process this referral if you do not have the permission of the person with parental responsibility What is their current school year? —Please choose an option—Pre-schoolReceptionYear 1Year 2Year 3Year 4Year 5Year 6Year 7Year 8Year 9Year 10Year 11Year 12Year 13Post-16N/A What is the name of their school/setting? What is the name of their SENDCo or Keyworker? What is school/setting's phone number and email address?* Are you happy for us to make contact with school immediately? YesNo Neuro-affirmative We are committed to neuro-affirmative practices. This starts by asking those seeking our services some optional questions, which will allow us to understand how you would prefer us to speak of neurodivergence in relation to your / your child's experiences. Do you consider yourself (or the person you are referring) to be neurodivergent? YesNo Which of the following terms do you prefer us to use when writing or talking about your (or the person you are referring's) experience of neurodivergence? Please tick any options you are comfortable with us using: Use of diagnosis (e.g., 'X has a diagnosis of ...')Use of cognitive descriptors (e.g., 'spikey' / 'uneven')Person first language (e.g., 'X is a person with autism')Identity first language (e.g., 'X is autistic' / 'a dyslexic person')Use of typology (e.g., 'neurotype' / 'neurodivergent' / 'neurodiverse', please note we do not use the term 'neurotypical')Use of emotional descriptors (e.g., 'dysregulation' / 'distress', please note we do not use the term 'EBSA' or 'avoidance', as they infer choice) Do you have any specific preferences for terms we should or should not use when writing about you (or your child's) experience of neurodivergence? What can we do to make your experience with us a comfortable and inclusive one? Your Request Which service(s) are you referring to?* AssessmentPsycho-legalTherapyOrganisationOther Is this referral part of a legal process (e.g., SENDIST, Civil, Family, etc.)? YesNo Do you have any deadlines? YesNo What are your deadlines?* Your hopes & wishes Please use this space to tell us a little about anything you think is important for us to know. This might include, for example, your main concerns and what you hope to get from our work together.* How did you hear about us?* Magazine/Newspaper adOnline adSearch engine (e.g. Google)Flyer/LeafletWord of mouthFacebookInstagramA sponsored eventOther (please specify) This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Tick this box if you are happy for us to contact you with PAPPS related news. Good to know ... we will NEVER pass your information on to others, you can unsubscribe any time, and we will only send very occasional updates (we don't do spam - not in our sandwiches, not deep fried, and certainly not to your inbox!). I have read, understood and agree to the terms & conditions.* Send Message