SPECIALIST SHORT BREAKSAPPLICATION FORM

1. CHILD’S DETAILS

Child’s Name / Date of Birth
Address
Postcode / CareFirst/Short break ID (if applicable)
Gender
Telephone Numbers
Home
Mobile
Do you consent to being contacted by Text / SMS? YES / NO
Do you consent to being contacted by email? YES / NO
If yes please provide email address: / Who has Parental Responsibility for the child?
Nationality / Language spoken / communication method
Ethnicity / Religion
GP name and contact details / School / Nursery attended
Professionals working with your child

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Specialist Short Breaks Application Form06/07/2017

2. OTHER HOUSEHOLD MEMBERSParents, siblings and other adults. Please also include parents not living in the child’s home who

haveParental Responsibility for the child.

FULL NAME (including Title, First and Surname) / DATE OF BIRTH / RELATIONSHIP
TO CHILD / ADDRESS AND TELEPHONE NUMBER IF DIFFERENT FROM CHILD’S / ADDITIONAL INFORMATION e.g. medical need, disability, English as second language

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Specialist Short Breaks Application Form06/07/2017

3. CHILD’S NEEDS

Disability/Medical Needs / Impact on Child

4. WHAT’S WORKING WELL Tell us what’s going well for your child and the family and what isn’t going so well.

What’s Working Well?
What’s Not Working Well/Needs To Change?

5. CURRENT SERVICES ACCESSEDPlease tell us about any out of school activitiesyour child attends. These could be provided by Health, Voluntary Organisations, Sports Clubs, After School Clubs, Holiday Play-schemes, Brownies, Cubs, Swimming, Horse Riding, Skiing, etc. Please tell us if your child has additional support in any of these settings?

Service(s) / Hours / Sessions per week / year
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2.
3.
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5.

6. ADDITIONAL INFORMATIONPlease tell us any additional information about your child or familyi.e. are there any other disabled children or adults in the family home, do you have any extended family or friends who support you in caring for your disabled child.

7. TELL US WHAT YOU HOPE YOUR CHILD WILL ACHIEVE IN THE NEXT YEARIF THEY ARE ALLOCATED ANY SPECIALIST SHORT BREAKSExamples are learning a new skill, attending an activity without parents, becoming more independenthaving access to social activities at weekends to meet with other families for outings.

8. TELL US WHAT YOU HOPE YOUR FAMILY WILL ACHIEVE IN THE NEXT YEAR BY YOUR CHILD HAVING SPECIALIST SHORT BREAKSExamples aretime to spend with other siblings or family members, more social opportunities.

9. SUPPORTING EVIDENCEWe will make our decision on eligibility and level of short breaks based on the information you provide in thisform and thesupporting evidence. Please provideas much supporting evidence as possible as this will enable us to offer you the appropriate package of support.

Please supply as many of the following as possible
School Annual Review – latest report, written in last 12 months / Essential
Education, Health and Care Plan (EHCP) orStatement of Special Educational Needs / Essential
Clinical or Educational Psychology Report
Detailed medical reports / letters - written in last 12 months
Family Service Plan
Transition Plan
Health Care Plan
Other relevant documents/assessments from other professionals working with your child/ familysuch as Starfish, Early Help
DLA/PIP – Please indicate which level of care and/or mobility your child receives

Care: Low Middle High

Mobility: Low High

Please note that applications received with no supporting evidence will not be accepted.

10. CONSENT TO HOLD AND SHARE INFORMATION

I / We consent to information in this application form and any supporting evidence being shared within Norfolk County Council and other organisations, i.e. Health and Education and Short Break providers.
Please inform us if there are any organisations you do not want this application form to be shared with:
Please indicate if you have any additional needs that we need to consider when processing the application, e.g. any learning difficulty, disability, English as a second language.
Name of Parent / Carer: Mr / Mrs / Miss / Ms
Signature: Date:
Name of Parent / Carer: Mr/ Mrs / Miss / Ms
Signature: Date:

TRANSITION TO ADULT SOCIAL CARE SERVICESBy the age of 16 we will automatically make a transition referral for your child to Adult Social Servicesunless you tell us not to.

Please ensure you send the application formand all supporting evidence with the correct postage to:

Children’s Services

Post Room Floor 3

Short Breaks Team

County Hall

Martineau Lane

Norwich

Norfolk

NR1 2DL

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Specialist Short Breaks Application Form06/07/2017