Referral Form

Q1 - Are you a disabled parent or carer?

parent

carer

neither

Q2 - Please provide some details of any relevant disabilites or health issues you may have:

Q3 - How many children in your family are aged:

5-11?

12-16?

Male?

Female?

Q4 - Have you ever had any challenges/difficulties in getting your children to school because of a health condition? If yes, please explain what the challenge/difficulty was:

Q5 - What was the impact of this challenge/difficulty on your children, you and your family?

Q6 - Were these challenges/difficulties resolved - if yes, how? If no, what were the barriers?

Q7 - How long were the children/young people absent from school? What impact did this have on them?

Q8 - Which services/departments do you think should be addressing this issue?

Thank you for taking the time to complete this questionnaire, if you would like to discuss further or are happy for us to contact you please provide your details.

Name:

Email:

Contact number:

The information provided by you will be treated anonymously and in confidence.