Request Parenting Support

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Support for Parents and Families
Request Parenting Support

Get in touch for support and information

If you require parenting support or wish to enquire about any of our groups or courses, please complete the below form and your local team will get back to you as soon as possible.

If you have any difficulties completing this form, please contact your local Family Hub.

Personal Details:

Note: Questions marked by * are mandatory

Herefordshire and Worcestershire Health and Care NHS Trust is required to comply with the laws and regulations that apply to protecting your data and how it is used. They are the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018.

In our Privacy Notice we will explain how we collect, use, store and protect your personal information. We will also explain what rights you have with regards to your personal information and how you can exercise those rights.

*This is a mandatory field. 1a. What is the main priority of help or support you require? (select only one)

Antenatal support
Tell me more about local groups and support services for me and my family
Request to attend a parenting group or course
Help with childcare funding
Other

1b. What other additional help or support, if any, do you require? (select all that apply)

Antenatal support
Tell me more about local groups and support services for me and my family
Request to attend a parenting group or course
Help with childcare funding
Other

1c. If you know which course/group you want to attend, please specify here:

1d. If you selected other in question 1a or 1b, please give further details

*This is a mandatory field. 2. Please give a brief description of the support required and any previous support received

Parent/carer details

*This is a mandatory field. 3. Parent/carer 1 first name

*This is a mandatory field. 4. Parent/carer 1 surname

*This is a mandatory field. 5. Address

*This is a mandatory field. 6. Postcode

*This is a mandatory field. 7. Parent/carer contact number

8. When is the best time for our team to contact the parent/carer?

*This is a mandatory field. 9. Can we leave voice messages?

10. Parent/carer email address

*This is a mandatory field. 11. Can we contact via email?

12. Name and address of child's GP surgery

13. Parent/ carer 2 first name

14. Parent/ carer 2 surname

15. Relationship to child for parent/carer 2

16. Address

17. Postcode

18. Parent/carer 2 contact number

19. When is the best time for our team to contact parent/carer 2?

20. Can we leave voice messages?

21. Parent/carer 2 email address

22. Can we contact via email?

Referrer Details

23. Name of Referrer

24. Job title of Referrer

25. Referrer's Organisation

26. Contact number of Referrer

27. Referrer's Email Address

28. Referral Date

*This is a mandatory field. 29. Has consent been obtained from parent/carer

Yes
No
N/A

Child details

*This is a mandatory field. 30a. Child 1 name (if child has not yet been born please specify)

*This is a mandatory field. 30b. Parent/carer relationship to Child 1

30c. Date of birth or due date of Child 1

30d. School/nursery attended (where appropriate)

30e. NHS number of Child 1

30f. Child 2 name

30g. Parent/carer relationship to Child 2

30h. Date of birth of Child 2

30i. School/nursery attended (where appropriate)

30j. NHS number of Child 2

30k. Child 3 name

30l. Parent/carer relationship to Child 3

30m. Date of birth of Child 3

30n. School/nursery attended (where appropriate)

30o. NHS number of Child 3

30p. Child 4 name

30q. Parent/carer relationship to Child 4

30r. Date of birth of Child 4

30s. School/nursery attended (where appropriate)

30t. NHS number of Child 4

Additional information

31. Please list any other agencies working with the family

*This is a mandatory field. 32. Do you or your child have any special educational needs or disabilities (SEND) we should be aware of?

*This is a mandatory field. 33. Does you have any communication support needs? E.g. large print, braille, interpreter

34a. If yes, please state support required

*This is a mandatory field. 35. Do you consent to your child's information being stored?

Yes
No
N/A

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Support for Parents and Families
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Children's Speech and Language Therapy
Looked After Children (LAC)
SEND (Special Educational Needs and Disability)
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Children and Adolescent Mental Health Services (CAMHS)

Head Office

Herefordshire and Worcestershire Health and Care NHS Trust
2 Kings Court
Charles Hastings Way
Worcester
Worcestershire
WR5 1JR

T: 01905 760000

Our Partners

Herefordshire and Worcestershire Health and Care NHS Trust

Action for Children

Redditch Borough Council

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