Unique Families Support Service Referral form

Child / Young Person Details
Legal name*

First NameLast Name
Preferred name (if different)

First NameLast Name
Date of birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

Town/CityCounty

Postcode
Young person's email (optional)
(only required for young people aged over 16 who are happy to be contacted by us directly)
Young person's phone Number (optional)
(only required for young people aged over 16 who are happy to be contacted by us directly)
Educational setting where the child / young person is currently registered (even if not attending)
Leave blank if not enrolled in any educational setting
Educational setting 2 (e.g. dual roll, PRU or alternative provision placements etc)
Leave blank if this does not apply
Does the child / young person have an Education, Health and Care Plan (EHCP)?*

NoYesAn application / assessment for an EHCP is in progress
Child / young person's preferred pronouns*

he / himshe / herthey / themOther
First language (if not English)

Professional Referral Form