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Parent submission form
Child's details:
Child's Forename and Surname:
Child's DOB:
Child's Ethnicity:
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Asian or Asian British - Indian
Asian or Asian British - Japanese
Asian or Asian British - Pakistani
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Other Black Background
Do not wish to disclose ethnic group
Mixed - Other Mixed Background
Mixed - White Asian
Mixed - White Black African
Mixed - White Black Caribbean
Other ethnic group
White - British
White - European
White - Irish
White - Other White Background
Child's gender:
Male
Female
Child's address:
City
Post Code
Current Pathway
ADHD
Autism
Both
Pathway Stage
Diagnosed
On waiting list
Suspected
Child's details:
Parent's name:
Contact Number:
Email address:
Preferred method of contact:
Email
Phone
Language Spoken:
Interpreter required:
Yes
No
Parental Responsibility:
Yes
No
Child's GP details:
GP Surgery:
GP Address:
Post code:
GP Phone number:
Childs NHS Number:
Any social care involvement?
Yes
No
How did you hear about GEMS?
Are you happy to be sent a Survey?
Yes
No
Reason for referral: Please provide as much information as possible about your current situation and what support you are interested in accessing from GEMS to support your family
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General Consent:
GEMS as part of Solutions4Health request consent for your personal information to be stored and also to be shared with our workshop delivery facilitators who require this in order to send you information related to the workshop. We also use non-identifiable information for reporting purposes. If at any point, there are concerns relating to safeguarding we are obliged to share relevant information. You can also remove your consent for us to store and share data at any time by writing in to gems4health@nhs.net
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