Blackpool SENDIASS Referral Form

Blackpool SENDIAS Service operate a 'self-referral' process. However, we may also accept referrals from schools, nurseries, colleges and other partners on the strict understanding that consent has been given for the referral by the parent, carer or young person.

We respond to referrals within 48 hours.

1. Child/Young Person's Details *

First Name	*
Last Name	*

2. Child/Young Person's Date of Birth *

	DD/MM/YYYY
DoB

4. Child/Young Person's Address *

Address Line 1	*
Address Line 2	*
City	*
Postcode	*

5. Child/Young Person's Setting / School / College name *

6. Other Professional/s involved *

7. Please advise what support you require *

If other, please specify