Parent submission form

Child's details:

Child's Forename and Surname:

Child's DOB:

Child's Ethnicity:

Child's gender:

Child's address:

City

Post Code

Current Pathway

Pathway Stage

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:

Solutions 4 Health would encourage you to provide your consent in order that we can process data and information about you. We will share this data where necessary with other health professionals such as your GP or specialist services. The information we collect and process will be used to help us meet the contractual obligations as set down by the local health service commissioners in accordance with the service we are providing. You can request to view, amend or delete your data at any time by contacting us at (www.Solutions4Health.co.uk/contact).

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