Request for Contact

1. Hello! Thank you for requesting contact from Normal Magic's Family and School based team for Primary Schools in Tavistock area only.

We would like to know how you got to hear about us: *

2. We pledge to adhere to the National Confidentiality Guidance as set out in the 2013 HSCIC Guide to Confidentiality as well as the UK GDPR Rules on Data Protection. Confidentiality is your right for any information about you that is shared with Normal Magic NOT to be shared with any other party unless you consent to do so either verbally or in writing. We will not share any of your personal information unless it is part of yours and our collaborative agreed plan.

Do you consent to your information being stored by Normal Magic? *

YES
NO

3. Please complete the following for Child or Young Person: *

Name	*
DOB:	*
Address:	*
Postcode:	*

4. Please complete the following about yourself. Are you the child or young persons...

Parent
Carer
Other

If other: please explain your connection with the child or young person

5. Contact Details of Parent(s)/Carers

Name of Parent(s)/Carers:
Contact Number:
Email Address:
Full Address (if different to child/young person):

6. Please provide the details for the following

GP Surgery
Name of School
Other education (eg home schooling):

7. Please briefly describe why you are requesting contact:

8. Are you wanting to explore the possibility of Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder for your child?

Yes
No
I don't know

9. Are you wanting to explore the possibility of Autism for your child?

Yes
No
I don't know

10. We will make contact with you within 1 week. Is there a preferred day or time you would like us to make contact with you?

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