Home-Based Short Breaks Service Referral Form

Section 1: The Child Being Referred

Key information about the child’s support needs. Additional information needed: - Copy of child’s care plan - Medical needs and requirements - Any known Safeguarding issues

Section 2: The Referring Agency
Section 3: Support Requirements

Please give us an indication of the number of hours support required per week and likely pattern of care required (if known)

Duration of service

Section 4: Payment ArrangemnetsDes

Sessions are charged at £26 per hour, with am Minimum charge of 2 hours per session.

Section 5: Contact Details

Glenys James
[email protected]
020 7183 5120 ext. 899