Fields marked with * are mandatory and must be completed.

Requesting a Service for a Child/Young Person

Do You Require a Service - For a Child/Young Person?

Please be aware that this form will only be dealt with during normal office hours -
Mon-Thur 8.30am - 5pm, Friday 8.30am 4.30pm.
Outside of these hours you can contact our Emergency Duty team on 01785 354030.

Do you require a service for yourself, or do you want to make a referral on behalf of someone else?

An assessment is carried out following a request for a service to this department.  It is usually done by a Social Worker in the home of the person being referred.

If you are requesting this service on your own behalf please complete PART A only.

If you are requesting the service on behalf of someone else please complete both PART A: - providing their details & PART B:- providing your details.

Please fill in the form below and then press the SUBMIT button to send the information to us.

The department needs to maintain personal records and you are entitled to access them. 

You may also access the 'Comments, Compliments and Complaints' form.

Part A - Details About the Child or Young Person Requiring a Service or Support

*

*


or expected due date



Address
*

*





Further Details About the Child or Young Person


*


*





*





Details of Child or Young Person's Main Carer

*


*



Main Carer's Address
*

*




*

*

Mother's Details If Not Main Carer

Mother's Address If Not Main Carer



Father's Details If Not Main Carer

Father's Address (if different from mother's address)


 

Other Family Members
Address(if different from above)






Address (if different from above)




Part B - Your Address

If you are making this request on behalf of someone else:

 










The department will need to contact you.  Please provide:

 

Press the Submit button to send us your completed form.

 Fields marked with *are mandatory and must be completed.