Your Details:
Full Name:
*
First Name
Last Name
Email:
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Format: 00 000 000000.
Organisation (if applicable):
Getting in Touch:
Preferred method of contact (select all that apply):
*
Phone
Email
Text
Best time to contact: (Select one or more)
*
Morning (9 AM – 12 PM)
Afternoon (12 PM – 4 PM)
Evening (4 PM – 7 PM)
About Your Enquiry:
Which best describes you?
*
Parent
Carer
Young Person
Professional
Other
Who is the enquiry about?
*
Myself
My child or a young person I care for
Someone I support professionally
General enquiry
Other
Where do you live or work?
*
North Ayrshire
South Ayrshire
East Ayrshire
East Renfrewshire
Glasgow City
South Lanarkshire
North Lanarkshire
Other
What Can We Help You With?
What are you interested in? (Select all that apply)
*
Child ASN Support
Young Adult Support
Life Skills Project (ages 14-25)
Professional Referral Information
Parent & Family Support
Holiday Support
Recruitment
Partnership Working
Name of Child or Young Person:
Child or Young Person's Date of Birth:
*
-
Day
-
Month
Year
Date
Address:
*
House Number and Street
Town
Post Code
How can we help?
*
Diagnosis (short description):
*
Indicative Budget:
*
Approximate Time Requirements:
*
Mornings, Afternoons, Evenings, Weekends, Holiday Cover etc
Requirements:
*
121 Community, 221 Community, 121 in Group, Group Support General (Please note group support only available in Ayrshire)
How Did You Hear About Us?
How did you hear about us?
*
Website
Facebook
Instagram
School
Health Professional
Social Work
Friend/Family
Event
Other
Consent
*
I consent to KO-NEKT/Connections for Families contacting me about this enquiry. I understand my details will only be used to respond to my enquiry.
Signature
*
Send My Enquiry
Send My Enquiry
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