PLEASE FILL IN THE FORM BELOW TO REQUEST ADVICE AND SUPPORT
SELF-FUNDING ADVICE
We are unable to offer reduced cost services for families who live outside of Gloucestershire. If this is your situation
then we request an initial agreement to fund 5 hours at a rate between £49 and £65 an hour, depending on the support needed plus a set-up fee of £25.
This cost will be agreed with you in advance and is on the basis that any unspent money would be refunded. Depending on the complexity of the case there may be a need for additional funds, but that is agreed with you before any additional hours are worked.
The advice will be provided in accordance with the
Service agreement
and
Terms and Conditions
ONLY fill in this form if you are happy to proceed in agreement with the service agreement and Terms and Conditions.
First Name
This is required.
Surname
This is required.
Email address
This is required.
Phone number
Please give a contact number
Please give a phone number
Postcode
Telling us your postcode helps us to help you
Is the concern urgent?
If there is a date soon that the assessment is needed for, such as a meeting or case conference please tell us here
Preferred contact time
Please tell us the best time(s) for an advocate to contact them to discuss your concerns
Please give some details of your concerns
Please tell us about why you would like advice and support and we will arrange for someone with the relevant skills to get in touch with you and find out more.
It would be useful to know what additional needs your child/young person has, what service(s) (e.g. education, social care etc.) are of concern and the type of issues that you have - failure to discuss/assess needs, failure to provide agreed needs, etc.
Child/Young person's additional needs
Please highlight all that apply, hold down the control key and click to select.
Austism Spectrum Disorder
Global Development Delay
Learning Disability
Profound and Multiple Learning Disabilities
Physical Disability
Wheelchair User
Long Term Health Condition
Mental Health Condition
Sensory Impairment
Stoma/Gastrostomy
Tracheostomy/Severe breathing difficulties
Other
Please help us to understand the needs of your child
Child/Young person's Other Additional needs
If you selected Other please give a brief description of these needs
Describe the issues you'd like to discuss
Please summarise your concerns so we can select the best adviser to help you
Please help us to understand the needs of your family
Which agencies are involved?
Please briefly describe this - health, education, social care etc.
EHCP details
If you are asking for support with an EHCP - draft, review or in preparation for Tribunal, please
click here
to send a copy of the EHCP for an Advocate to review.
Have you emailed us an EHCP?
Yes I have emailed an EHCP
No
How do these concerns affect you/your family?
Please share your experiences
Please help us to understand the needs of your family
What support do you hope we can provide
Please tell us how we could help
Knowing how you'd like us to support you helps us decide who would be best to advise you
Have you had support from the Alliance before?
Yes I have had Support before
No
Please select one option
Do you agree to provide Feedback on support provided to you?
Yes I agree to give feedback
No
Please select one option
CONSENT TO SHARE NOTICE
I have read and understood the Parent and Carer Alliance Privacy Policy,
click here
to read the Privacy Policy
By proceeding, I consent to my personal data being collected and used as stated in the Privacy Policy, and in this Notice
:
The Parent and Carer Alliance wish to collect and use this personal information for the following reasons:
To enable you to sign up for services, advocacy, training, information events, social activities and outings;
To provide you with support and guidance that is tailored to your needs;
To provide relevant future events/training and services by understanding your personal situation and experiences;
To help us to demonstrate need both locally and nationally to help the Parent and Carer Alliance work effectively with other organisations to improve the services provided;
To access funding sources to develop what we can offer to our members and to offer reduced price support;
To request feedback from you about what you think about any service or support provided to you by the Parent and Carer Alliance e.g. feedback to the National Lottery of the impact of advice and support that you have received as a direct result of their providing funding, which may involve them contacting you; and
To track information about the use of our website including information obtained via cookies to develop the website.
You can withdraw your consent to share your information at any time without detriment by email to info@parentandcareralliance.org.uk
Consent to share information
YES I DO consent to share this to access advice and support
No
Please let us know if you consent to share this information
Submit
Please click the submit button below to send this form and we'll be in touch as soon as we have Advocates available. Once the button is clicked a please wait message should appear, then disappear and be replaced by a thank you message at the TOP of the form. You will then be emailed a copy of the form, showing that it has been submitted.
If this doesn't happen, please scroll up for any error messages, as questions with a red star need to be answered for the form to submit. Any issues
click here
to contact us
Submit
AFTER CLICKING SUBMIT SCROLL UP TO CHECK THAT A 'THANK YOU' MESSAGE APPEARS. YOU WILL BE SENT A COPY OF YOUR COMPLETED FORM AND WILL BE CONTACTED SOON.
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