Referral Form

Make a Referral
Please note, referrals will only be accepted for our current Growing Hope clinics
Are you a professional making a referral on someone else's behalf?*

YesNo, I'm making a referral for my own child

Professional's information

Please provide your contact details.
Name*

First NameLast Name
Email address*
example@example.com
Contact Number*
Phone number
Profession/Role:*
Please note our therapy clinics currently offer the therapies indicated below. We are unable to accept referrals for a therapy that is not yet offered in your chosen clinic.

King's Cross - Speech and Language, Occupational, and Music
Brockley - Counselling, Occupational
High Wycombe - Speech and Language, Occupational, Music and Art
Maidstone - Music
Which clinic are you referring to (where does the child live)?*

Camden / Islington (King's Cross clinic)Lewisham / Southwark (Brockley clinic)High Wycombe (High Wycombe clinic)Maidstone (Maidstone clinic)None of the above
We are only able to accept referrals for children who live within the areas of our current clinics.

For therapy activities and advice (including quick reference resource sheets and 10 minute podcasts), please go to growinghope.org.uk/resources

Parent/Carer information

Please provide the contact details for the parent/s or carer/s of the child you are referring for.
Parent/Carer Name*

First NameLast Name
Second Parent/Carer Name

First NameLast Name
Parent Contact Number*
Please enter a valid phone number.
Parent Email*
example@example.com
Parent's Address*

Street Address

Street Address Line 2

CityRegion

Post code

Parent/Carer information

Please provide your contact details.
Parent/Carer name:*

First NameLast Name
Second Parent/Carer name:

First NameLast Name
Parent/Carer email address: *
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityRegion

Postal Code
Is the address above the same as your child's address?*

YesNo
Please provide your child's address below
Please note our therapy clinics currently offer the therapies indicated below. We are unable to accept referrals for a therapy that is not yet offered in your chosen clinic.

King's Cross - Speech and Language, Occupational, and Music
Brockley - Counselling, Occupational
High Wycombe - Speech and Language, Occupational, Music and Art
Maidstone - Music
Which clinic are you referring to (where does your child live)?*

Camden / Islington (King's Cross clinic)Lewisham / Southwark (Brockley clinic)High Wycombe (High Wycombe clinic)Maidstone (Maidstone clinic)None of the above
We are only able to accept referral for children who live within the areas of our current clinics.

For therapy activities and advice (including quick reference resource sheets and 10 minute podcasts), please go to growinghope.org.uk/resources

Child information
Name of child being referred*

First NameLast Name
Child's date of birth*

DayMonthYear
Date
Name of Child's School/Nursery*
Please type N/A if your child is not yet in school or nursery
School year of child*
What is the child's first language?*
What language is spoken at home? Please list any other languages spoken by the child.
Please summarise who is in the child's family and in their home*
Growing Hope offer support, groups and training for parents, carers and siblings. If you'd like to find out more about these, please select any that apply:

Siblings group is a 7-week course for primary school aged siblings to connect with others and process their feelings and experience.When Dreams Change is a 4-week course for parents and carers to process their experience of having a child with additional needs.Circle of Security is an 8-week course based on attachment theory for parents and carers about supporting their children with their emotional regulation.Bi-weekly free online parent training sessions led by our team of therapists on topics such as communication, sensory processing, hand writing, etc.Accessibility support for families who would like to attend our partnership churches.Growing Hope High Wycombe run in-person workshops on child behaviour. The sessions focus on providing information and strategies to support challenging behaviour, and are run by a Child Behaviour Specialist. These sessions are open to parents and carers living within the High Wycombe area.

Therapy
Please note our therapy clinics current offer the following specific therapies:
- King's Cross - Speech & Language, Occupational, Music
- Brockley - Counselling, Occupational
- High Wycombe - Speech & Language, Occuapational, Music, Art
- Maidstone - Music
We are unable to accept referrals for a therapy that is not yet offered in your chosen clinic.
I'd like to refer for...*

Occupational TherapySpeech and Language TherapyMusic TherapyArt TherapyCounselling
Occupational Therapy

Occupational therapy helps with everyday activities that a child participates in, whether that is washing, dressing, eating, playing, handwriting or something else. Occupational therapists look to see if there’s anything that a child finds difficult and then at how they can help to make it easier. They see both children with diagnosed needs and significant disabilities, and those with undiagnosed needs and general concerns about coordination.
Speech and Language Therapy

Speech and language therapy helps children and young people with their communication skills, so that they are able to understand other people better and clearly communicate their own thoughts and ideas to others.
Music Therapy

Music Therapy session will generally involve songs used each week to start and end the therapy and then time in between for free musical play. Here your child and the therapist will use instruments to improvise, providing space for expression and opportunity to work towards individualised goals.
Art Therapy

Art therapy is a place for children/families to come and express themselves through the artmaking, play and exploring various art materials. This work is based on a safe therapeutic relationship and the client/s can use the materials to express themselves, which is particularly helpful for those who struggle to verbally express themselves. The client/s can decide what they would like to use and the therapist follows the process, working with what the client/s decides to bring up. Goal-based and short-term work is also possible with Art Therapy.
Counselling

Counselling sessions offer an opportunity to think about how we are feeling and how best to understand and cope with those feelings, with someone who is completely separate from our family or school. We normally do this through playing, chatting, drawing and writing.

Consent

I confirm I am the child's parent/ carer or I have gained consent from the child's parent/carer to complete this referral.*
I confirm that I am over 18*
I consent to Growing Hope contacting me in relation to Growing Hope's services and to holding and processing my data on a secure email system and encrypted database. I confirm that I have read and agree with the Privacy Notice (linked below).*
Please find Growing Hope's Privacy Notice here.
Would you like to sign up to our monthly newsletter?

Yes, I'd like to sign up to the newsletter
I heard about Growing Hope...
If you selected 'Other', please specify:
Newsletter

Yes, subscribe me to this newsletter.
Should be Empty:

	Bath/ shower	Dressing	Zips/ clasps	Eating
With complete adult assistance
Able to help a little
Able to do with full supervision and prompts
Able to do with some prompts
Indepedent

	Drinking	Grooming (hair washing, brushing, nail cutting)	Getting ready for school	Making food
With complete adult assistance
Able to help a little
Able to do with full supervision and prompts
Able to do with some prompts
Independent

	Doing chores	Toileting	Writing/ drawing	Cutting	Typing
With complete adult assistance
Able to help a little
Able to do with full supervision and prompts
Able to do with some prompts
Independent

Make a Referral

Professional's information

Parent/Carer information

Parent/Carer information

Child information

Communication skills

Social skills

Behaviour and emotional regulation

Everyday activities

School participation

Motor skills

Sensory processing

Diagnosis

Therapy

Please note our therapy clinics current offer the following specific therapies:

We are unable to accept referrals for a therapy that is not yet offered in your chosen clinic.

Occupational Therapy

Speech and Language Therapy

Music Therapy

Art Therapy

Counselling

Consent

	First Name	Last Name	Profession	Email
Professional 1
Professional 2
Professional 3
Professional 4