PAC-UK Referral Form

Please include as much detail as possible on the referral form below. Fields highlighted with a red * symbol are mandatory and must be completed in order for you to submit the form.

At the bottom of the form there is a verification code you must enter before pressing submit (this is an anti-spam measure). The verification code can be any two digits of your choice, for example 12.

Once you have pressed submit, your form will automatically be sent to the PAC-UK Advice Line who will respond at the earliest possible opportunity. A notification message will appear on your screen confirming your referral has been received.

All information processed in relation to your enquiry and/or booking adheres to PAC-UK's Privacy Policy.

Note, failure to provide enough information could result in delays. Please read each question carefully to ensure all contact details provided are correct.

Client /Parent 1


Client /Parent 2 (if applicable)


Referring Local Authority /Agency

  • Disability

  • How did you hear about PAC-UK? (tick as applicable)

  • What is the family's religion? (tick as applicable)


Referred child/ren

    Child 1

  • Child 2 (if applicable)

  • Child 3 (if applicable)


Name of all other family /household members

    Family member 1

  • Family member 2

  • Family member 3


Details of referral


Medical information


School /Nursery


Contact details of Social Worker for the CHILD (if different)


Invoicing details (if already known at this stage, please provide us with details of the person who will be dealing with this transaction)


Verification (for anti-spam)