PaIRs self-referral form

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PaIRs self-referral form

The PaIRS self-referral form is for people who live in Blackpool, Blackburn with Darwen and Hyndburn.

Please tell us the area you live in Required

Blackpool

Blackburn with Darwen

Hyndburn

Parent/Caregiver First name* Required

Parent/Caregiver Surname Required

Date of Birth Required

Date

Your Address Required

Address 1

Address 2

City

Country

County

Postal Code

Contact number Required

Can we leave a voice mail on this number Required

Yes

Can we send text messages to this number Required

Yes

Baby/child first name (if born)

Baby/child surname Required

Baby/child Date of Birth (or Estimated Due Date) Required

Date

GP Surgery name

GP phone number

We work closely with other services and professionals and may need to contact them in order to ensure we work together to get you the most appropriate support. Please list the services/ professionals you are involved with.

Do you consent to us contacting these services for more information to help us decide on the best support for you?

Yes

Reason for Requesting support from PaIRS Required

Do you require any adaptations to meet your needs e.g. interpreter, sign language, or any neurodiversity adjustments?

Please tick the box below to confirm you consent to this referral. (Please note that we can only accept this form if the person has consented). Required

Yes I consent to this referral.

I agree to the privacy policy