Lamplight API response

First name

Last name

Address 1

Address 2

Address 3

Postcode

Email address

Mobile phone

Phone number

Does the individual being referred consent to being contacted in the following ways?

By post

By email

By mobile

By text message

Other information

Is the address provided temporary or permanent?

Have the family had any experience of referral to any of the following?

Refuge

Sanctuary Scheme/Safer Accommodation/Home Refuge

Fled home because of domestic abuse

None

Note: If it is not safe to contact the individual on the above address, please provide an alternative contact address below

Alternative contact address for reference

Client location - please note we are currently only accepting referrals from Reading, Wokingham, West Berkshire, Oxford City, Vale of the White Horse and South Oxfordshire *

Is this person an adult or a child? *

Date of birth *

Relationship to child/children being referred *

Gender identity: how does this person describe themselves? *

Gender identity: is this person's gender identity the same as the gender they were given at birth? *

Preferred pronouns *

Sexual orientation *

Ethnicity *

Primary language *

Does the individual have a disability? *

Details of disability (if applicable)

Any special needs? *

Mental Health

Physical Health

Learning difficulties

Sensory needs

Behavioural issues

None

Unknown

Details of special needs (if applicable)

Occupation

Please confirm that to the best of your knowledge there are no known court orders in place prohibiting the referred parent from exercising sole parental responsibility *

If you are aware of any court orders prohibiting the referred parent from exercising sole responsibility, please give details here

Family information:

Total number of children in family unit

Number of children being referred for BB4K support

Please add below the names of any children NOT being referred at this time that you would like to notify us of (including their name, age and any important details):

Parent/carer agreement to support:

Have all the BB4K support programmes been explained to parent/s or carer/s? *

Has the parent/carer agreed to support? *

Would the parent/carer agree to one-to-one telephone support? *

Can the parent/carer and child(ren) being referred commit to a 6/8-week programme? *

Any other information relevant to this referral?

Data protection:

In submitting this form, your confirm that the parent/guardian and child(ren) being referred agree that the information contained within can be held securely at BB4K for the purposes of proceeding with support as outlined in the BB4K privacy policy.

A link to the privacy policy can be found at the bottom of this form (a child-friendly version is also available)

Please confirm you agree to BB4K storing your data as outlined in the BB4K Privacy Policy *

If the referral does not proceed we will delete all data given within 18 months from the date the decision was made to decline the referral.

How we store information and how we use data will be discussed with the parent/guardian during their first meeting at BB4K. Further consent for their data to be stored will be sought.

Referral source:

If you are referring yourself, please choose 'self-referral' as the referral source, and then skip the next section. If you are referring a client, please choose an option and then add your own details below.

Referral source *

Details of referrer (if not self-referral):

Referrer first name

Referrer last name

Organisation

How long has the referrer known/worked with the family?

Referrer contact number

Email address - please provide a direct email address in case we need to contact you directly; NO generic emails please

IMPORTANT: after submitting this form, please return to your email to ensure you also complete referral forms for each child being referred

When you are ready, please click 'Save Details' below. PLEASE ONLY CLICK THE BUTTON ONCE - it can take a few seconds for the form to save. If you need any help or have any problems completing this form, please get in touch at bb4k@pactcharity.org

You can read our privacy policy here