Professional Referral Form

Your Details

Your Title*

Your Name*

First Last

Organisation

Contact email*

Please note this will only be used to contact you about this referral unless otherwise indicated.

In what capacity do you work with/support the child?*

As the referring individual, are you willing to provide a supporting statement should this be needed? WellChild will be in contact with you if this is needed and will provide guidance on what information is required. Yes/No

Yes
No

Parent Carer Details

Parent's Name*

First Last

Parent's Address*

Parent's Postcode*

Parent's Address*

Street Address City Postcode Country

Parent's Phone Number*

Parent's Email*

*please note these will only be used to contact the parent carer about this referral unless otherwise indicated.

Child's Details

Child's Name*

First Last

Is the child in receipt of continuing care support?*

Yes
No

Is the child aged 0-19 years?*

Yes
No

Date of Birth

Does the child have complex medical needs?*

Yes
No

What are the child’s three main conditions?

Condition one*

None of the above - Please specify*

Condition two

None of the above - Please specify*

Condition three

None of the above - Please specify*

Does the child have a terminal illness, and is not expected to live more than 12 months?*

Yes
No

What medical equipment and/or mobility aids does the child you are referring need/use? Please use the three drop downs below to tell us about the main aids/equipment needed.

None of the above - Please Specify*

Is the child currently in hospital?*

Yes
No

Is the child in residential accommodation?*

Yes
No

If the parent carer is happy to share, please tell us the child’s sex

Is there a particular time of day to contact you?

What support would the parent carer like? (tick all that apply)

Support researching and applying for a grant
Support with application for Disability Living Allowance (DLA)
Support with application for Personal Independence Payment (PIP)
Support researching and accessing local services
Support with food or fuel for their home e.g. gas/electric
Other

How did you hear about the Family Welfare Advisor Service?*

Please add any other information that may be useful for this referral.*

Declaration*

I confirm the family is aware that I am making a referral to the WellChild Family Welfare Advisor service on their behalf, and are happy to be contacted by WellChild?

Declaration*

I confirm the family is aware that by being referred they will also be added to the WellChild Family Tree Network. As part of this they will receive family focussed mailings including information, events, activities and more which they can unsubscribe from at any time, using the link at the bottom of the mailings.

Declaration*

I confirm that I have been given consent from the parent carer to share their details and information with WellChild for the purposes of accessing support from the Family Welfare Advisor service.

Declaration*

I confirm that where the child is aged 13 or over and able to understand what giving consent means, that they have consented to having their details shared with WellChild for the purposes of accessing support from their Family Welfare Advisor service.

Declaration*

I confirm that the family, if successful, with any application will provide the any evidence as needed such as DLA/PIP award letters.

Keeping you updated – Be the first to know!

Your support is important to us. We want to keep you updated about our work, the events and campaigns we are planning and the opportunities to get even more involved. Please tell us if and how you would prefer to hear from us by ticking the boxes below. If you are happy with your previous communications preferences, please leave blank.

Select All
Email
Phone
Post
SMS

We promise to never sell or swap your data and to keep your information safe – to see more about this see our Privacy Policy. If you don’t want to hear from us again or change your mind about how we contact you please let us know by emailing [email protected]

Professional Referral Form

Your Details

Parent Carer Details

Child's Details

Sign up for regular email updates