Referral Form - Full Assessment

Referral Form: Full Assessment
SECTION 1 OF 3
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.

It is not possible to save this form so please complete all sections and check for errors before submitting.

This form must be completed and signed by both of the child’s legal parents/carers, unless there is only one legal parent/carer due to bereavement or where safety/welfare issues apply.

Click to read: EdPsych4Kids Privacy and Data Protection Policy
Privacy note (UK GDPR): EdPsych4Kids handles personal and sensitive data in line with UK law. We may use trusted AI tools to help with administrative tasks—this is done ethically, securely, and with parental permission (where required). Do you consent to the processing of your child's personal data in accordance with EdPsych4Kids Privacy & Data Protection Policy?*
Do you consent to receiving a copy of this form via email?*
Child's legal name*

First NameLast Name
Name your child prefers to be called
Child's date of birth*

DayMonthYear
I have checked my child's name and date of birth are correct.*
Child's age*
Child's school year*
Child's gender*
Child's ethnicity*
Languages spoken by parents/carers*
Languages spoken by child*
Child's address*

House number or name

Street

Town/CityCounty/Local Authority

Postal/Zip CodeCountry
Parent/Carer 1*

First NameLast Name
Parent/Carer 1 phone number*
Please enter a valid phone number.Format: 00000-000000.
Parent/Carer 1 email*
example@example.com
Parent/Carer 2

First NameLast Name
Parent/Carer 2 phone number
Please enter a valid phone number.Format: 00000-000000.
Parent/Carer 2 email
example@example.com
Have contact details been given for both the child's legal parents?*
Child's education provider*
Education provider name and address*

Name of education provider, eg school, nursery, tutor, parent

Street

Town/CityCounty/Local Authority

Postal/Zip CodeCountry
Phone number to contact education provider. If your child is home educated or receives an EOTAS package, please give the contact number for the person/organisation legally responsible for providing your child's education:*
Please enter a valid phone number.Format: 00000-000000.
Email to contact education provider (they will be sent an online form to complete). If your child is home educated or receives an EOTAS package, please give the contact email for the person/organisation legally responsible for providing your child's education:*
example@example.com
Do you give permission for a copy of the report to be sent to your child's education provider?*
Does your child have an Education Health and Care Plan (EHCP)?*
Please select from drop down options
If relevant, please upload your child's most recent EHCP, Annual Review or EHC Needs Assessment Request:

Cancelof
How did you hear about my services
Please briefly explain your reasons for this referral. How do you hope the assessment and report will help your child?*
Fees
Full assessment and written report (includes letter and certificate for your child): £1795
I would like to include an observation at my child's education setting: £185Outcomes for an EHCP: £300 (Recommended if your Local Authority has requested outcomes as part of a Needs Assessment that has been agreed, or if you are updating an EHCP as part of an Annual Review)
I understand
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.*

I understand and my child is in Year 9 or aboveMy child is in Year 8 or below
Review: Some children benefit from a review after their assessment. For example, if further targeted teaching or referrals to other professionals are required before I can conclude a diagnosis. Reviews can be requested any time within 6 months after the assessment. Please discuss this with Hannah Morris. If you decide to request a review, then the fee will be £385. You will be required to confirm agreement via email.*

I understand
EdPsych4Kids was established by Hannah Morris, Principal Educational Psychologist (EP). We have grown in recent years, and all our Associate Educational Psychologists are qualified, highly skilled, and caring. Reports are delivered in the same format and quality-assured by Hannah. Your child's assessment will be carried out by an EdPsych4Kids EP based on location and who is available to help the soonest. If you are not comfortable with this, please contact us to discuss options.*

I understand
I understand
Who completed this section?
SIGNATURE
By signing section 1 of this document, you confirm that:

- You are the child's legal guardian

- Information shared is true to the best of your knowledge

- You understand that sharing inaccurate information may result in your child's assessment being cancelled and this contract being void

- You agree to the fees selected above

- You consent to the processing of your child's personal information in accordance with EdPsych4Kids Privacy & Data Protection Policy
This section was completed by: Signature of 1st parent or carer *

Clear
Please write your signature or initials
Name of 1st parent or carer *

First NameLast Name
Signature of 2nd parent or carer where applicable

Clear
Please write your signature or initials
Name of 2nd parent or carer where applicable

First NameLast Name
Date of signature/s*

DayMonthYear
Have both the child's legal parents signed?*

Terms and Conditions
SECTION 2 OF 3
IMPORTANT INFORMATION
- Please read this document carefully before signing. It contains important information about safety, confidentiality, data protection, cancellations, fees, and assessment procedures. 

- Please scroll down inside each box to read all the information.

- These terms form a legally binding agreement under UK contract law.

1. PAYMENT
- Hannah Morris reserves the right to accept or decline this referral. This contract is only valid once you have received email confirmation of an assessment date.

- If this referral is accepted, an invoice will be issued on the first day of the month in which the assessment takes place, unless agreed in writing by Hannah Morris.

- Full payment is required within 3 working days of the invoice being sent, unless agreed in writing by Hannah Morris.

- If an education setting is paying fees in full or part, payment is required at the time of booking.
2. CANCELLATION & RESCHEDULING
- Cancellations must be submitted in writing at least 14 calendar days before the agreed assessment date (inclusive of weekends and holidays). Cancellations made with fewer than 14 calendar days notice will incur a £500 cancellation fee.

- If a child is unwell or cannot engage with the assessment on the day, a new appointment may be offered at the next available date and at the discretion of Hannah Morris.

- If your child is unwell, please telephone or text Hannah Morris as soon as possible. A £50 charge will apply if no prior notice is given before an EdPsych4Kids Psychologist travels to a an appointment, unless there are extenuating circumstances. 

- Hannah Morris reserves the right to rearrange observations and assessments at short notice in the event of exceptional circumstances (e.g. if the Psychologist's children are unwell). In such cases, a new appointment will be offered at the next available date.

- If your child has sickness, diarrhoea, and/or a cold that substantially affects their hearing, energy, and/or concentration within 48 hours of their scheduled assessment, please telephone or text Hannah Morris as soon as possible, as the assessment may need to be rescheduled.

- The assessment will be rescheduled if a child's symptoms of illness will negatively affect the reliability of test scores and/or be detrimental to their wellbeing or the wellbeing of the Psychologist, as determined at the discretion of Hannah Morris. In such cases, a new appointment will be offered at the next available date.

- The assessment will be rescheduled if a child's symptoms of illness may possibly be contagious, as determined at the discretion of Hannah Morris. In such cases, a new appointment will be offered at the next available date.

3. PROFESSIONAL PRACTICE
- Assessments identify a child's strengths and needs using a triangulated approach: combining information from background documents, assessments, and observations.

- Specific learning difficulties such as dyslexia and dyscalculia, as well as general learning difficulties and intellectual giftedness, can be formally diagnosed when there is sufficient evidence. These conclusions are based on a comprehensive evaluation and are not made on test scores alone.

- Diagnostic outcomes cannot be guaranteed, as a formal diagnosis requires clear and sufficient evidence. In some cases, additional assessment or targeted intervention may be necessary before a diagnostic conclusion can be established.

- Other developmental areas, such as autism and ADHD, are not diagnosed as part of this service but they can be screened for, and referrals for formal diagnostic assessments may be recommended.

- A written report will be provided up to 4 weeks after your child's assessment (excluding holiday periods), and includes recommended strategies and resources for supporting your child's education. 

- Sometimes reports take longer to write and you will be contacted in the event that there is a delay in your child's report being written.

- Information from parents, education providers, and young people are considered. Psychological conclusions and recommendations are based on the Psychologist's professional judgement and may be different from the views shared by parents, education providers, and young people. Amendments are made at the Psychologist's discretion.

- If you have concerns about the service you receive from EdPsych4Kids, please initially contact Hannah Morris. The Complaints Policy is available on the EdPsych4Kids website. 

4. ASSISTANT EDUCATIONAL PSYCHOLOGISTS
Assistant Educational Psychologists (AEPs) may support the work of EdPsych4Kids Psychologists as part of their professional development.

EdPsych4Kids AEPs:

- Are trained in safeguarding and follow the EdPsych4Kids Safeguarding Policy

- Work under the supervision of a qualified Psychologist 

- May access your child's personal data solely for administrative or training tasks

- May temporarily store your child's personal data on their devices for administrative or training tasks

- May use and/or store anonymised documents indefinitely for professional development

- May shadow a Psychologist during observations and assessments (your consent will be requested in advance)

- Adhere to EdPsych4Kids Health & Safety and Privacy & Data Protection policies
5. DATA PROTECTION
- Personal data is processed and stored in accordance with UK law.

- Artifical Intelligence (AI) tools are used to support administrative tasks, which may include processing your child's personal data. Psychological conclusions and recommendations about your child are made by the Psychologist. 

- AI tools are used in compliance with the UK law.

- A Data Protection Impact Assessment (DPIA) is reviewed annually to ensure safe handling of personal and sensitive data. 

- Personal data may be processed by Stream Systems (streamsystems.co.uk) to support the management of the website, email communications, and referral processes.

- The Privacy & Data Protection Policy is available on the EdPsych4Kids website.
6. DATA STORAGE & DELETION
- All personal data is securely stored and shared electronically with password-protected or encrypted systems compliant with UK law.

- Physical documents are kept in locked storage.

- You have the legal right to request access to, amendments to, or deletion of your child's personal data. Hannah Morris may seek legal advice before responding to requests.

- Anonymous case discussions may take place for supervision and professional development. Hannah Morris may use or store anonymised documents indefinitely for professional development.

- Your child's personal data is deleted or destroyed once the retention period expires, unless there is a valid reason to retain it longer (e.g. ongoing legal proceedings or safeguarding concerns).

Retention Periods:

- Children and young people aged up to 18 years old: Retained until the client reaches age 25, or 7 years after the last contact, whichever is later

- Adults aged over 18 years old: Retained for 7 years from the date of last contact

- Personal data relating to safeguarding: Retained indefinitely, as advised by a lawyer, or as required by UK law

- Financial records (e.g. invoices): Retained for at least 6 years, in accordance with HMRC requirements, or longer if advised by an accountant

- Correspondence and emails: May be retained in line with the above, otherwise deleted if no longer needed
7. CONFIDENTIALITY
- EdPsych4Kids reports are shared electronically with encryption or password protection. Paper copies are not provided.

- Communications, such as emails, may include your child's name and date of birth for identification purposes. 

- Your child's data will only be shared with consent from a legal guardian unless required under UK Law (e.g. safeguarding or court requests.)

- If your child is considered to have sufficient understanding (Gillick competence), their consent may be required before carrying out assessments and sharing information about them. 

- Reports may be temporarily stored on a personal device and proof-read by a person or organisation appointed by Hannah Morris; they adhere to EdPsych4Kids Safeguarding, Health & Safety and Privacy & Data Protection policies. All personal data accessed for proof-reading is deleted after use.
8. SAFETY & SAFEGUARDING
- Equipment and facilities are cleaned regularly to reduce health risks.

- Potentially harmful items, such as kitchen knives, are stored out of sight.

- Hannah Morris and all Associate or Assistant Educational Psychologists working with EdPsych4Kids are not liable for any injuries, to any person or animal, that may occur during assessments, observations, or visits, in any and all locations.

- Responsibility for your child's safety remains with the accompanying adult or, in educational settings, is shared with school staff in accordance with safeguarding responsibilities. 

- Safeguarding children is a core responsibility of Hannah Morris and all Associate or Assistant Educational Psychologists working with EdPsych4Kids. All work is carried out in line with the EdPsych4Kids Safeguarding Policy and adheres to statutory guidance.

- Hannah Morris and all Associates or Assistant Educational Psychologists working with EdPsych4Kids hold Disclosure and Barring Service (DBS) certificates and undertake safeguarding training every two years.

- Hannah Morris reserves the right to cancel assessments at any time if she believes that continuing would be unsafe for anyone involved or not in your child's best interests.

- The Health & Safety and Safeguarding Policies are available on the EdPsych4Kids website.
9. PRE-ASSESSMENT REQUIREMENTS
9. PRE-ASSESSMENT REQUIREMENTS

- If your child uses glasses or hearing aids, please ensure they bring them to the assessment. Without them, the assessment will not be able to go ahead.

- You will be sent a Strengths and Difficulties Questionnaire, which must be completed before you are offered assessment dates.

- If pre-assessment requirements are not adhered to, Hannah Morris may offer to reschedule the assessment at her discretion at the next available date.
Who completed this section?
SIGNATURE
By signing section 2 of this document, you confirm that:

- You are the child’s legal guardian

- Information shared is true to the best of your knowledge

- You understand that sharing inaccurate information or omitting information may result in your child's assessment being cancelled and this contract being void

- You understand and accept the above terms and conditions

- You consent to the processing of your child's personal information in accordance with EdPsych4Kids Privacy & Data Protection Policy
Signature of 1st parent or carer *

Clear
Please write your signature or initials
Name of 1st parent or carer*

First NameLast Name
Signature of 2nd parent or carer where applicable

Clear
Please write your signature or initials
Name of 2nd parent or carer where applicable

First NameLast Name
Date of signature/s*

DayMonthYear
Have both the child's legal parents signed?*

Referral Form: Full Assessment

SECTION 1 OF 3

Fees

Who completed this section?

Terms and Conditions

SECTION 2 OF 3

Who completed this section?

Background Information Form

SECTION 3 OF 3

Professionals Supporting Your Child

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