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.

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 and you will receive a copy of your form via email.

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

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

PAC-UK Referral Form
Client/Parent 1
Name
Name
First
Last
Address
Address
Address Line 1
Address Line 2
Address Line 3
City
Postcode
This should include anyone listed in 'other household members' and 'details of children' sections of this form.
This should include anyone listed in 'other household members' and 'details of children' sections of this form.
Can the person/s being referred be contacted directly by PAC-UK?
Client/Parent 2 (if applicable)
Name of Client/Parent 2 being referred
Name of Client/Parent 2 being referred
First
Last
Address
Address
Address Line 1
Address Line 2
Address Line 3
City
Postcode
Referring Local Authority/Agency
Address of Local Authority/Agency
Address of Local Authority/Agency
Address Line 1
Address Line 2
Address Line 3
City
Postcode
Please note, a copy of this referral form will be sent to the email address entered here.
Would you like us to add your email address to our PAC-UK Training and Newsletter mailing lists?
All our PAC-UK mailouts include 'unsubscribe' options.
How did you hear about PAC-UK? (tick as applicable)
Referred child/ren
Full Name (Child 1)
Full Name (Child 1)
First
Last
Full Name (Child 2)
Full Name (Child 2)
First
Last
Full Name (Child 3)
Full Name (Child 3)
First
Last
Name of all other family/household members
Full Name (Person 1)
Full Name (Person 1)
First
Last
Full Name (Person 2)
Full Name (Person 2)
First
Last
Full Name (Person 3)
Full Name (Person 3)
First
Last
Details of referral
Details of current identified need and service requested – please provide as much detail as possible and include any Child-on-Parent-Violence issues if applicable.
PAC-UK will try to accommodate preferred days and times for sessions when possible, subject to availability of staff. If there any days or times that the person/s being referred definitely cannot attend, please list here on the understanding that this may increase their waiting time to receive a service. Please note, all confirmed appointments that the person/s being referred to does not attend are chargeable.
Please advise us of any safeguarding or contact issues. It is important that this information is provided from the outset to enable planning of our services.
Please list any other information or issues we should be aware of at this stage here.
Please identify any relevant reports such as CPR, PAR, Annexe A, Adoption-Support Assessments, psychological reports, etc. that will be available once the referral is accepted.
Please advise which Services have been accessed, whether any psychological diagnoses were made, and whether any services are currently being accessed; please attach reports using the below 'Reports Upload' field.
Medical information
GP Address
GP Address
Address Line 1
Address Line 2
Address Line 3
City
Postcode
School /Nursery
School Address
School Address
Address Line 1
Address Line 2
Address Line 3
City
Postcode
PAC-UK Education Service
PAC UK has an Independent Education Service which can provide bespoke training to schools, parent/school consultations, transition support, advice line and Guidance on Pupil Premium Plus. Please indicate if you would like to receive this information. This can be posted to you or sent via email.
Contact details of Social Worker for the CHILD (if different)
Social Worker Address
Social Worker Address
Address Line 1
Address Line 2
Address Line 3
City
Postcode
Invoicing details (if already known at this stage, please provide us with details of the person who will be dealing with this transaction)
Address
Address
Address Line 1
Address Line 2
Address Line 3
City
Postcode

Maximum file size: 16.78MB

If you would like to send supporting documents with this referral please upload here before pressing the 'Submit' button.

Maximum file size: 16.78MB

If you would like to send supporting documents with this referral please upload here before pressing the 'Submit' button.

Maximum file size: 16.78MB

If you would like to send supporting documents with this referral please upload here before pressing the 'Submit' button.