Do you give consent for us to speak and liaise with your child's educational establishment?
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Yes
No
Ordinary Magic is part of the Connected Care Network which provides holistic care for children and young people across Solihull to meet their physical and mental health needs. Do you give consent for this child to be part of the network and for a triage call to be undertaken? North Solihull ONLY
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Yes
No
Referrer's Name
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First Name
Last Name
Referrer's Address
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Street Address
Street Address Line 2
Town
City
Post Code
Referrer's Number
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Please enter a valid phone number.
Format: (00)0000 000 000.
Referrer's Email
*
example@example.com
Do you have consent to make this referral?
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Yes
No
Child's Name
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First Name
Last Name
Child's Date of Birth
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-
Month
-
Day
Year
Date
Address child resides at
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Street Address
Street Address Line 2
Town
City
Post Code
The school the child attends - If home schooled or not in education please state.
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If relevant - The Child's Year and Class
Parent/Carer's Name
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First Name
Last Name
Parent/Carer's Address
*
Street Address
Street Address Line 2
Town
City
Post Code
Parent/Carer's Number
*
Please enter a valid phone number.
Format: (00)0000 000 000.
Parent/Carer's Email
*
example@example.com
Reason for referral
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Has the child experienced trauma?
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Yes
No
Maybe
If Yes or Maybe to the above question, please provide details:
Does the child have a disability, do you suspect they may have additional needs or are you awaiting a diagnosis?
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Yes
No
Maybe
If Yes to the above question, please provide details:
What support do you think would be helpful to the child? - If you don't know please leave this blank.
Address of the GP Surgery the child is registered to
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Street Address
Street Address Line 2
Town
City
Post Code
Submit
Should be Empty: