Internal registration form

Internal registration form

YesNo
Name of professional *

First NameLast Name
Email of professional *
example@example.com
Phone Number*
Please enter a valid phone number.Format: 00000000000.
Organisation/Service*
Yes
YesNo
Please note Children and Young People should only be referred to either Out and About or Holiday Short Breaks. Referrals should NOT be made to both services.
- Child or Young Person
- New FormUpdate to a previous form
- WECILKhaasFACESENSE
- Name:*
  
  First NameLast Name
- Child or Young Persons preferred name:
  If different to their actual name
- Date of Birth: *
  
  DayMonthYear
- MaleFemalePrefer not to sayOther
- Full Name of School*
- Ethnicity *
- MainstreamSpecialResidentialHospitalOther
- Parent or Carer
- Name*
  
  First NameLast Name
- Relationship to Child or Young Person*
- Mobile Phone Number*
  Please enter a valid phone number.Format: 00000000000.
- Home Phone Number
  Please enter a valid phone number.Format: 00000000000.
- Email*
  example@example.com
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postcode
- YesNo
- YesNo
- Details on parent/carer support needs/disability
- Emergency Contact Information
  
  This should be a different contact to the parent/carer contact information added above
- Name*
  
  First NameLast Name
- Phone Number*
  Please enter a valid phone number.Format: 00000000000.
- Relationship to Child or Young Person*
- Permissions and Consent
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- Signature
  
  Clear
- Yes
- Disability Information
- YesNo
- Social Workers Name
- Social Workers Phone Number
  Please enter a valid phone number.Format: 00000000000.
- Autism Spectrum ConditionMental/Emotional DistressChallenging BehaviourPhysical ImpairmentSensory ImpairmentComplex Health NeedsDeaf (BSL User)Speech ImpairmentVisual ImpairmentLearning Difficulties (Mild)Learning Difficulties (Moderate-Severe)Long Limiting IllnessPrefer not to answerOther
- Please provide further details with regards to your child's needs below.
  
  The more information you provide the better we will be able to identify appropriate support for your child.
- Behaviour *
- Communication (Sign, Makaton, Verbal, Non-Verbal etc.) *
- Individual Support Needs*
- YesNo
- Please provide further details where necessary:
- Dietary Requirements
- YesNo
- Please provide further details where necessary:
- YesNo
- Please provide further details where necessary:
- YesNo
- Please provide further details where necessary:
- Please provide details of any religious or cultural requirements we need to be aware of:
- Please provide further information you feel like we should know about your child or young persons needs including if you have already been in contact with Out and About
- Please upload any Care Plans etc. That you feel would be beneficial for supporting your child or young person.
  
  Cancelof
- Medical Information
- YesNo
- Please provide details of their allergies:
- YesNo
- YesNo
- Please provide any further details on their Asthma:
- YesNo
- YesNo
- Please provide any further details on their Epilepsy:
- Please upload any relevant Epilepsy Plans and/or Risk assessment's
  
  Cancelof
- YesNo
- Please provide further details:
- YesNo
- Please provide further details:
- Please provide further details on anything you feel like we should know about your child or young persons medical needs:
- Befriending
  
  The befriending service is delivered by volunteers who meet with Children or Young People on a 1:1 basis.
- YesNo
- WHO IS THE BEFRIENDING SERVICE APPROPRIATE FOR? THE SERVICE IS SUITABLE FOR DISABLED CHILDREN AND YOUNG PEOPLE WHO:
  - Are aged 5 to 18 years old
  - Can form an ongoing befriending relationship with a volunteer.
  - Have behaviour which allows a volunteer to look after them safely 1:1.
  - Need or would benefit from 1:1 support to achieve more independence from their primary carers and take part in social and leisure activities
  - Have a parent or carer who would benefit from a short break.
  - Would ideally like a volunteer for between 2-4 hours a week on a regular basis.
  THE BEFRIENDERS ARE UNABLE TO:
  
  Help with intimate personal care or frequent help with lifting and moving. If in the home parent/carer can.
  - Help with medication or medical procedures from their volunteer.
  - Have a home situation which would cause their volunteer to be unsafe when visiting (i.e. hygiene and basic safety standards within the home, risk to injury within the home etc.).
  - Need a volunteer to stay after midnight.
  - Are in crisis.
  We are not able to place a volunteer with a child who has unpredictable or unmanageable behaviour which could place them self and others at risk.
  
  There is no guarantee a suitable volunteer will be found and placed.
- Volunteer Requirements
  
  To make sure we can try to source a volunteer who meets the needs of your family please let us know what you would require from a volunteer.
- Please provide detail on any specific requirements you/your child or young person may need from a volunteer:
- 18-2526-3536-4545+
- MaleFemaleN/A
- What availability would you be looking for in a volunteer?
  Please note most volunteers commit to 1-2 hours per week
- Personality of volunteer (E.g. Patient, Chatty etc.)
- Any lifestyle interests
- Why would you like a befriender?
- YesNo
- Assessing Vulnerability and Prioritising Need Process
  
  We collect this information in order to help us prioritise children and young people who need the service the most
- Direct PaymentsDisability BenefitsRespite Services (E.g. Bush or Belbrook)Means tested BenefitsAttend any clubs, after school activitiesOther
- KhaasTime2Share @ WECIL (Befriending)WECILFACENone
- CommunicationPersonal CareAwareness of DangerEating/DrinkingMobilityMedical CareCultural NeedsOther
- YesNo
- If you have available please upload a copy of their EHCP:
  
  Cancelof
- Full TimePart-TimeHome EducatedOther
- YesNo
- On a scale of 0-5 how would you describe your child’s current experience with bullying?*
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None, 5 is
- On a scale of 0-5 how would you describe your personal/family support network?*
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None, 5 is
- YesNoNo Comment
- YesNo
- Please provide further detail:
- Are you interested in a specific service ? EG Southmead Adventure Playground, Play etc
- YesNo
- Should be Empty: