Momentum Children’s Charity is an independent charity providing support to families. This is separate from clinical care and choosing to be referred will not affect treatment in any way.

Patient details (please answer all questions, use capitals if handwritten)

We ask for this information so we can understand the needs of the child and family and assess how we may be able to support. Please only include information that is necessary to support this referral.
Name(Required)
Date of Birth(Required)
Please provide a brief overview only. Detailed medical information is not required at this stage.
Date of Diagnosis(Required)
If you do not know the exact day of diagnosis please just estimate a day as close as possible.
Family is in receipt of free school meals or pupil premium

Primary carer details

Name(Required)

Other carer details. Please leave blank if N/A

Name

Sibling details: Please leave blank if N/A

Sibling 1 – Name
Sibling 1- Date of birth
Family is in receipt of free school meals or pupil premium
Sibling 2 – Name
Sibling 2- Date of birth
Family is in receipt of free school meals or pupil premium
Sibling 3 – Name
Sibling 3- Date of birth
Family is in receipt of free school meals or pupil premium

Grandparent details (if support highlight as needed, consent needed for details to be shared). Leave blank if N/A

Name

How we can support. The information will be used to monitor how our support meets the family's needs.

Which services would benefit the family?
Momentum Children's Charity would love to keep in touch. Please tick the box below if you would like to join our email mailing list for news, and ideas of how to get involved .

Declaration- I declare that the above information is accurate:

This form cannot be submitted unless you can confirm that you have discussed this referral with the family and explained Momentum’s services.
Have you discussed this referral with the family?(Required)
DD slash MM slash YYYY

*Why are we asking for this information?

i) to help our team to use the most respectful language when addressing ii) for equality and diversity monitoring purposes iii) for our grant reporting requirements iv) occupation and school information can help with tailoring our communications appropriately and highlight most relevant ways for involvement with Momentum should you wish to in future

How we use this information

Momentum Children’s Charity will use this information to contact the family, assess their needs, and provide appropriate support. We may share relevant information with professionals involved in the child or young person’s care where necessary to support them. In some circumstances, we may also need to share information to meet our safeguarding responsibilities. You can read more about how we use personal data here: https://www.momentumcharity.org/privacy-policy/


IMPORTANT: We may share relevant information with professionals involved in the child or young person’s care to ensure they receive the appropriate support. All information will be handled confidentially and shared only when necessary and in line with our privacy and data‑protection policies.