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ND Family Support Referral Form

Support for families with a child or young person who is on the neurodevelopmental pathway, incorporating Amaze's ND Family Training & Navigation Service, Parent Groups & Befriending and Amazing Futures - young people's activities.

This service is funded by the NHS. We need some details about you and your children, so that we can report on the work that we are doing to support you. Please read our privacy policy and NHS consent guides here.

Please select the area in which you live.*

In which area is your child/ren’s registered GP?*

Sorry this service is currently only funded to support families living or registered with a GP in Brighton & Hove or East Sussex.

Please confirm that you are happy for Amaze to store the information you provide in this form about yourself and any children under 16 years, and that you have parental responsibility for all children you tell us about. For further information, please see our privacy policy.*

About what you would like from ND Family Support

What would you like to access from Amaze ND Family support service? (Select ‘yes’ for all that apply and at least one option)

Navigation call offering information and advice for parents about neurodevelopmental conditions, local pathways and support

Please tell us the first names of the child/ren (or young person) you would like a navigation call about and why. We will take more details about these children/young people later in the form.

Training (workshops, courses & info sessions on neurodiversity)

Parent groups & befriending and wellbeing activities

Information about Amazing Futures - Young person activities (14 -25 years)

About you: Your name and contact details

Your first name*

Your last name*

Your email address*

Your mobile number*

Your landline number

First line of your address*

Second line of your address

Town/city*

Postcode*

What is your gender identity?*

Your age range (please ignore the lower age ranges, these come directly off our system)*

Is spoken English your main language at home?*

What is your main language at home?*

Do you consider yourself to have a disability, long term health condition or are neurodivergent?*

About your children or young people with SEND

For any young people aged 16 up to 25 years, please confirm they have consented for you to share their information with us (Amaze).*

This service is funded by the NHS, we ask that you consent to us sharing some data about your children, as described here with the MHSDS. This is used in an anonymised way to report on how our service performs and its impact.

Please confirm that you are happy for us to share certain characteristics of the child/ren you detail in this form with the MHSDS (NHS dataset).*

How many of your children with SEND would you like us to support you with? We can collect information for up to 3 children on this form, but ND navigation support is available for more children.*

Details of the first child or young person you would like to tell us about

What is your relationship to them?*

Child or young person’s first name*

Last name*

Child or young person's date of birth*

Their gender identity*

What was their sex assigned at birth?*

What is their ethnicity?*

What is the name of their GP practice and town?*

What is the main condition of the child (or concern) that prompted you to contact us today?*

Please select ALL the conditions and at least ONE condition, which may apply to this child/young person. For autism and ADHD we also ask where they are on the pathway.

Autism

ADHD

Tics/Tourette's Syndrome

Fetal Alcohol Syndrome (FASD)

Learning Disabilities/Developmental Delay

Social communication concerns

Sensory processing difficulties

Any other ND conditions not listed, such as developmental language disorder, dyspraxia, dyslexia, dyscalculia?

Details of the second child or young person you would like to tell us about

What is your relationship to them?*

Child or young person’s first name*

Last name*

Child or young person's date of birth*

Their gender identity*

What was their sex assigned at birth?*

What is their ethnicity?*

If they are registered with a different GP practice, please provide the practice name and town

What is the main condition of the child (or concern) that prompted you to contact us today?*

Please select ALL the conditions and at least ONE condition, which may apply to this child/young person. For autism and ADHD we also ask where they are on the pathway.

Autism

ADHD

Tics/Tourette's Syndrome

Fetal Alcohol Syndrome (FASD)

Learning Disabilities/Developmental Delay

Social communication concerns

Sensory processing difficulties

Any other ND conditions not listed, such as developmental language disorder, dyspraxia, dyslexia, dyscalculia?

Details of the third child or young person you would like to tell us about

What is your relationship to them?*

Child or young person’s first name*

Last name*

Child or young person's date of birth*

Their gender identity*

What was their sex assigned at birth?*

What is their ethnicity?*

If they are registered with a different GP practice, please provide the practice name and town

What is the main condition of the child (or concern) that prompted you to contact us today?*

Please select ALL the conditions and at least ONE condition, which may apply to this child/young person. For autism and ADHD we also ask where they are on the pathway.

Autism

ADHD

Tics/Tourette's Syndrome

Fetal Alcohol Syndrome (FASD)

Learning Disabilities/Developmental Delay

Social communication concerns

Sensory processing difficulties

Any other ND conditions not listed, such as developmental language disorder, dyspraxia, dyslexia, dyscalculia?

About how you would like us to contact you in the future

The ND Family Support team will be in touch soon by email, we'd also like to know if you would like to receive other emails from us.

Would you like to receive emails from us about SEND issues, courses and workshops we think you might be interested in? This could be based on the information you have provided to us about you or your child.*

Would you like to receive the Amaze termly e-newsletter about SEND issues and news? If so, please select the area.*