Parents as Partners Self- Referral Form

Do both parents agree to attend the Parents as Partners group?

YesNo

In order to progress with the application we require both parents to be willing to attend Parents as Partners sessions together. Please have a conversation with your co-parent and come back to us if you both agree to proceed with this application.

Personal Details- Parent 1

First Name

Last Name

Date of Birth

Relationship to Children

Mobile Number

House Number/Name and Street Address

Postal Code

City

GP Details

We ask for your GP details to enable us to arrange support in the event of an emergency, or to support access to local statutory services for better coordinated care if this was thought to be helpful. If we need to liaise with your GP will we discuss this with you first.

Name of GP (if known)

GP Practice Name and Address

Registration Continued

Children

	Name	Age
Child 1
Child 2
Child 3
Child 4

Does one of the children have global developmental delay?

YesNo

Please provide details

Does your family receive help from any professional agencies (health, social services, voluntary organisations)?

YesNo

Please provide details

Parents as Partners

Please let us know why you are interested in attending the Parents as Partners group

How did you hear about Parents as Partners?

Please provide details

Parent 2

To enable us to register your co- parent for this service, please provide us with their contact information. It is important you obtain their consent to sharing this information with us.

First Name

Last Name

Email Address

Phone Number

Date of Birth

Relationship to Children

House Number/Name and Street Address

City

Postal Code

Co-Parent GP Details

Name of GP (if known)

GP Practice Name and Address

Availability

Please say what times on a Thursday you are both available to attend group sessions together:

Availability

Please click "Next Page" to proceed

Data Protection

The privacy of our clients is paramount. Please read our privacy notice on how we use and store your information, and confirm that you consent to us using your personal information as described.

I have read and agree to the privacy notice

YesNo

Questions or concerns?

Please speak to a member of staff in order to proceed with your referral 0207 380 1960

Please click "Next Page" to proceed

Next Steps

You will then be contacted by one of the Parents as Partners team who will arrange to meet you both for an initial consultation.

In the consultation you will meet the Group Leaders, who will ask you a little more about your reasons for wanting to participate and what you would hope to get from the programme. If after the consultation session we all agree this is the right support for you at this time, you would be invited to join a group.

The group sessions are online, last for 2 hours and run for 16 weeks and regular attendance is important if you are to get the most out of the programme.

Please click submit to complete your referral.

Contact Information