Referral Form -Therapywise

Referral Form

Name of Child

Date of Birth

Disability/Special Needs

Covid-19 Vaccination Status

Name of Parent(s)/Carer(s)

Please indicate who has parental responsibility for child (if different to above)

Child's Legal Status

Child's Home address

Parent/Carer Phone Number

Parent/Carer Email Address

Other Significant Family Members

GP & Surgery Address

Child’s School & Teacher (if applicable)

Other Significant Professionals who have been/are involved with the child (please give details)

Please give reasons for referral

Name of Person Making Referral

Phone Number of Referrer

Date of Referral

Referring Organisation (if applicable)

Address of Referring Organisation (if applicable)

Phone Number of Referring Organisation (if applicable)

Email of Referring Organisation (if applicable)

Safeguarding Children and young people: The Therapywise Foundation works to maintain the safety of any child, young person or adult using the provided premises. I am happy to discuss with you any issues that may need to be taken into account to guarantee that safety.

If there are any concerns about the safety or welfare of a child or young person the Therapeutic Team at The Therapywise Foundation have a responsibilty to report those concerns in line with Child Protection Procedures.