Which local authority is the child’s GP in?*

Has parental responsibility for the child/young person*

Has consented to this referral and is aware that we will be contacting them*

Understands that the data you are sharing with us will be stored on our systems as outlined in our Privacy Policy*

If the young person is aged 16 to 25 years, they have consented for their data to be shared with Amaze or if they lack capacity to consent for themselves their parent carer has consented.*

Your first name*

Your last name*

Your landline/mobile*

Your email*

Your job title*

Your organisation’s name*

Tell us why you are making this referral*

Does the parent carer have any additional needs or contact preferences we need to consider before calling or emailing them? If yes, tell us what.*

Child/YP’s first name*

Child/YP’s last name*

First line of child/YP’s address*

Second line of child/YP’s address

Town/city*

Postcode*

Child/YP’s date of birth*

Child/YP’s gender identity*

What was their sex assigned at birth?*

The child/YP’s pronouns, leave blank if unknown

If pronouns are not listed, which pronouns should we use?

The child/YP’s ethnicity, leave blank if unknown

What is the name of the child/YP’s GP practice and town? Put N/A if unknown.*

Autism

ADHD

Tics/Tourette's Syndrome

Fetal Alcohol Syndrome (FASD)

Learning Disabilities/Developmental Delay

Social communication concerns

Sensory processing differences

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

Does the parent carer want navigation support about any other of their children on a neurodevelopmental pathway, if so, how many? (put 0 if none)

Parent carer first name*

Parent carer last name*

What is their relationship to the child or young person you have referred?*

Parent carer email address*

Parent carer mobile number*

Parent carer landline number (if applicable)

Does the parent carer live at the same address as the CYP?*

First line of parent carer’s address*

Second line of parent carer’s address

Town/city*

Postcode*

What is the parent carer’s gender identity?*

Is spoken English your main language at home?*

What is the main language spoken at home?*

Does the parent carer require an interpreter?*

Name of person who can help with communication

Phone number of person who can help with communication

What is their relationship to the parent carer?