• Referral Form: Full Assessment

  • SECTION 1 OF 3

  • If you need help with this form please contact EdPsych4Kids.com

     

    Use this form to refer your child to EdPsych4kids. Please allow sufficient time to complete the form and ensure you have documents to upload ready before you begin, e.g. reports from other professionals or school.

    This form must be completed and signed with a signature by both of the child’s legal parents/carers, unless there is only one legal parent/carer due to bereavement. If there is another reason why a living second legal parent/carer cannot sign, please contact Hannah Morris at EdPsych4Kids.com BEFORE completing this referral.

    Click to read: EdPsych4Kids Privacy and Data Protection Policy

    If you need support to read and/or understand this form, please contact us at EdPsych4Kids.com and we will arrange for an Assistant EP to complete the form with you by telephone.

     

    To save and complete this form later:

    • Type your email in the relevant box below (Parent/Carer 1 email).
    • Scroll down and click the 'save' button (at the bottom of each section).
    • A Jotform box will appear - at the bottom click 'skip create an account.'
    • Type your email in the new box that appears. You will then be sent an email to continue completing the form at a later stage.
    • It may take up to 5 minutes to receive the email.

    When the form is completed please click 'submit' at the bottom of the last page.

    Thank you for considering an assessment with EdPsych4Kids. We look forward to receiving your child's referral.

  • Child's date of birth*
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  • Format: 00000-000000.
  • Format: 00000-000000.
  • Format: 00000-000000.

  • If your child is home educated or receives an EOTAS package, please give the contact email for the person/organisation who teaches your child, such as a tutor or online school, or who is legally responsible for providing your child's education.

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  • Fees

  • Optional:
  • Form 8 or 9 for GCSEs/A Levels - If your child's school want to use test scores from an EdPsych4Kids assessment to request exam access arrangements, they may need an assessor to complete relevant sections of these forms. In accordance with access arrangements guidelines, this must be agreed with your child's school in advance of their assessment with EdPsych4kids. Please discuss this with Hannah Morris. If this service is required, the fee will be £80. You will be required to confirm agreement via email.*

  • Who completed this section?

  • Date of signature/s*
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  • Terms and Conditions

  • SECTION 2 OF 3

    On some devices, you may need to tap inside each box and scroll down to read the text.

  • Who completed this section?

  • Date of signature/s*
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  • Background Information Form

  • SECTION 3 OF 3

  • Does your child have a history of hearing difficulties?*
  • Does your child wear hearing aids?*
  • Does your child have a history of eyesight difficulties?*
  • Does your child wear glasses or lenses?*
  • Does your child have any difficulties with school attendance?*
  • Does your child present with any aggressive behaviours at home or school, even if unintentional?*
  • Are there any concerns about drug or alcohol use involving your child or a family member?*

  • Professionals Supporting Your Child

  • Please select all professionals that have been involved in supporting your child:*
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  • How have you shared information from other professionals? Select all that apply:*
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  • Who completed this form?

  • Date of signature/s*
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