Parent Carer Referral Form

The children we support will be life-limited, disabled, or will be reliant on medical equipment to sustain life, for example:

Children on long-term ventilation
Children on dialysis
Children on parenteral nutrition

Some of the children we support will not be reliant on medical equipment, but still require a high level of additional support from health professionals and often have a complex regime of medication management.

Does the child or young person you care for have a long‑term or complex health condition (including any long-term effects of previous cancer treatment) that requires ongoing medical care, specialist equipment or adaptations at home, and/or long‑term medication to manage?

Yes
No

Is the child or young person aged 19 or under?

Yes
No

Does the child or young person currently receive a continuing care package e.g. do they have paid carers providing care for them?

Yes
No

WellChild Eligibility Response

Thank you for completing our eligibility form for the WellChild Family Welfare Service.

The Family Welfare Advisor Service is currently only open to families caring for a child with complex medical conditions and:

Caring for a child/young person aged 0 to 19.
Not receiving continuing care support.

Unfortunately, you have not met the specific eligibility criteria for this service. For more information, please see the service criteria on our website Family Welfare Service | WellChild and our eligibility statement.

If you disagree and think you should be eligible, please contact us at [email protected].

If you are a parent to a child with complex medical needs, but do not meet the specific eligibility criteria for this service, you may wish to join our WellChild Family Tree - Join Our Community | WellChild or seek support via one of our other services listed below:

Emergency Support Service - Emergency Support for Parent Carers | WellChild
Information Hub - Information | WellChild – sharing articles, guides and useful resources when caring for a child with complex medical needs, including this article about grants for families: Grants for Families | WellChild.
In Your Area - In Your Area | WellChild – a newly launched platform that makes searching for accessible services, places, and activities easier.

If you are not a parent to a child with complex medical conditions, here are a list of other charities which help disabled children and their families:

Cerebra - Working with you and your amazing child
Contact: The charity for families with disabled children
Parent Talk - Support for Parents from Action for Children

I hope the above information is useful to you.

Parent/Carer's Details

Title *

Name *

First Last

Address *

Please note this is a pilot service and we are currently only taking referrals from families who are living in the North-West of England.

Postcode *

Address *

Street Address City Postcode Country

Phone *

Email *

Your email address and phone number will only be used in connection with our Family Welfare Service and to receive information for families, unless you opt in to other marketing information at the end of this form.

Are you a member of our WellChild Family Tree network?

Yes
No

Next will be some equality & diversity questions for you to answer about you. Please only answer if you are happy to share this information. WellChild exists to provide support and programmes that benefit all children with complex needs across the UK and their families; we need to understand who our families are. To do this, we must look outwards and engage our families, gathering information to ensure our work and charitable activities are inclusive and representative of the society we live in. Providing answers will help us do this.

How would you describe your national identity?

What is your ethnic group?

Please indicate your religion/faith?

Child's Details

Child's Name *

First Last

Is your child in receipt of continuing care support? *

Yes
No

Continuing Healthcare is a package of care for people who have a 'primary health need' as a result of disability, accident or illness. This will often include a ‘package’ of carers to help care for the person at home during the day/and or night either provided via a care agency or employed by a parent/guardian using a Personal Health Budget. If you do have this in place, please answer ‘Yes’ for this question.

Is your child aged 0-19 years? *

Yes
No

Date of birth

Does your child have complex medical needs? *

Yes
No

What are your 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 your 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?

Is your child currently in hospital? *

Yes
No

Is your child in residential accommodation? *

Yes
No

If you are happy to share, please tell us your child’s sex

Is there a particular time of day to contact you? *

Mornings
Afternoons
Evenings

What Support Would You 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

Other *

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

Next will be some equality & diversity questions for you to answer about your child. Please only answer if you are happy to share this information. WellChild exists to provide support and programmes that benefit all children with complex needs across the UK and their families; we need to understand who our families are. To do this, we must look outwards and engage our families, gathering information to ensure our work and charitable activities are inclusive and representative of the society we live in. Providing answers will help us do this.

How would you describe your child's national identity?

What is your child's ethnic group?

Please indicate your child's religion/faith?

Declaration *

I confirm that by completing this form, I understand that my details and my child’s details will be shared with WellChild for the purposes of accessing support from their Family Welfare Advisor service.

Declaration *

I confirm that by completing this form I will be added to the WellChild Family Tree network and will receive family focused mailings about information, events, activities and more which I can unsubscribe from at anytime using the link at the bottom of the mailings.

Declaration *

I confirm that where my 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 I will provide any evidence or documentation as needed such as DLA/PIP award letters.

Consent *

I give WellChild consent to store and use the information provided within this form, and any subsequent related correspondence whether written or verbal, for the purpose of processing and considering my Family Welfare Advisor support application and any other support application WellChild submit on my behalf.

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]

Parent Carer Referral Form

Parent/Carer's Details

Child's Details

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