Are you a parent looking for support or a professional wishing to refer a family?

If you would like to access our Family Support service you can refer yourself, simply click on the Online Self Referral button below or call us on 01782 938912.

If you are a health professional, school, family support worker or in a any other profession working with a family you feel would benefit from our support you can make a referral on their behalf as long as they agree to the referral being made.

Online Self Referral Form

How to use this form

If you are a parent looking to access our support please complete the self-referral form below.

There is another form for Professional Referrals which can be located above this form.

Many of the fields in this form are optional, some fields are mandatory. If the field has an asterisk beside the description of the field you have to put some information in the field before submitting the form.

If you encounter any problems using this form please contact us on the following number: 01782 938912 or 01782 437981

When you have completed the form click on the submit button at the bottom of the form. When a form is submitted you will be taken to a “Thank You” page to confirm that the application was sent successfully.

About your family

All items marked in red are required to submit the form.

Parent's Name*

Please enter your full name

Parent's email address*

Please enter a valid email address we can use to contact you

Parent's date of birth*

dd/mm/yy

Contact telephone number*

Do not place any gaps in the number. It may help if this number can be used with WhatsApp

Best time to call you?*

Enter the best times and days that we can call you

Family's postal code*

Please enter your postal code so we can check you are in our area

Family's Address*

Please enter your family address here

Ethnic Background

This information is required for equality and diversity monitoring purposes only.

Please select one of the options below*

Ethnic Background

Please enter the name(s) and date(s) of birth for the child/ children

Child 1

Child 1 name*

Please enter the name of the youngest child dd/mm/yy

Child 1 date of birth*

Please enter the date of birth of the child dd/mm/yy

Child 1 gender*

select an option

Child 1 ethnicity*

Select an option

Child 2

Child 2 name

Please enter the name of the youngest child dd/mm/yy

Child 2 date of birth

Please enter the date of birth of the child dd/mm/yy

Child 2 gender

select an option

Child 2 ethnicity

Select an option

Child 3

Child 3 name

Please enter the name of the youngest child dd/mm/yy

Child 3 date of birth

Please enter the date of birth of the child dd/mm/yy

Child 3 gender

select an option

Child 3 ethnicity

Select an option

Child 4

Child 4 name

Please enter the name of the youngest child dd/mm/yy

Child 4 date of birth

Please enter the date of birth of the child dd/mm/yy

Child 4 gender

select an option

Child 4 ethnicity

Select an option

Please list the details of any other children in the family

Please list the names and dates of birth of any other children in the family

Please tell us about the support you need and anything about your situation:

How do you want your support delivered?

We review the referrals weekly and will discuss if your support would be best suited to one of our Family Support Volunteers, our Family Support Advisor or our information, advice and guidance service. Please indicate how best you feel you can be helped, and would like the majority of your support to be:

SelectHome-Visiting

SelectTelephone

SelectEmail

SelectVirtual

Privacy Policy

Please indicate your acceptance of our privacy policy which can be found here Privacy Policy (opens in a new window).

Please read our privacy policy before submitting the details you have provided to us

What happens next?

In the first place, we will give you a call, and check the information on the referral, clarifying any points that may need a bit more information. This helps us understand better what your needs are and the best way that we can help.

Following this call, you will start off receiving regular ‘keep in touch’ telephone support calls, which may be weekly, fortnightly for less often if this suits your circumstance, whatever suits your needs.

During these calls, we will find out if you need help in your family home from one of our family support volunteers, or some short term intervention by our Family Support Advisor, or whether having a volunteer telephone befriender will work best for you.

We can let you know what the wait times may be for these services, but rest assured that we will keep in touch with you via telephone calls and will do our best to ensure the same staff member or volunteer calls you each time, so they get to know you and your family’s needs.

In the meantime, before you get your initial call from us, we would like to share with you some useful contacts or websites that may be beneficial.

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Next: Useful Links