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Referral Form

Aiming Higher Referral Form

Please ensure ALL sections are completed thoroughly. In the case the form is not completed with enough information the referral may be returned and this would delay the family being offered support from our service.

We are currently unable to accept referrals for family support due to our waiting list but we are accepting referrals for all other services –  counselling,  rising stars under 5s groups, family trips and activities, The A Team and parent/carer sessions.

If you would prefer to send in a referral form via post, in person or manually via email you can download our Word Format version at the bottom of the page.

Please return completed form to

    Step 1 of 7

    Parent/Carer Details 1

    Do you have a disability or any form of ill health (including mental health)?

    Parent/Carer Details 2

    Do you have a disability or any form of ill health (including mental health)?

    Step 2 of 7

    Details of Child 1 with disability

    Details of Child 2 with disability

    Step 3 of 7

    Additional Children/Siblings

    Aiming Higher support the whole family and include siblings wherever possible.

    Sibling details

    Sibling details

    Sibling details

    Sibling details

    Sibling details

    Sibling details

    Sibling details

    Sibling details

    Sibling details

    Sibling details

    Sibling details

    Step 4 of 7
    Are there any of the following in place?

    Parental consent must be in place to attach these documents to this referral.

    Early Help Assessment

    2MB Limit - PDF, Doc & docx accepted

    Child In Need Plan

    2MB Limit - PDF, Doc & docx accepted

    Child Protection Plan

    2MB Limit - PDF, Doc & docx accepted

    Are there any known risks we need to be aware of?

    (for example: volatile behaviour in the home, dogs, disputes with neighbours, drug/alcohol use)

    Step 5 of 7

    Details of all Current Support/Services Involved with the family

    (eg. Doctor/Specialist, Health visitor, CAMHS, SENCO)

    Organisation Name
    Contact Name
    Contact Number

    Step 6 of 7

    Services available at Aiming Higher

    Please tick all services you are interested in accessing.

    If you require a Family Support Worker, what support do you and your family require?

    Step 7 of 7

    Referrer Details

    Is this a self referral?

    Consent Details

    All consent may be withdrawn at any time in line with UK data protection laws

    Has the parent/carer consented to this referral?

    Has the parent/carer consented to Aiming Higher making contact directly with them by phone?

    Has the parent/carer consented to Aiming Higher making contact directly with them by email?

    Has the parent/carer consented to Aiming Higher adding them to their email mailing list? (to receive details of events, activities and their quarterly newsletter. This mailing list is never shared or sold to other parties)

    Has the parent/carer consented to the sharing of any documents attached to this form?

    When the parent/carer us allocated a Family Support Worker - the support worker will make 3 attempts to communicate with the parent/carer. If they do not hear back from the parent/carer within 2 weeks from the date of the first communication attempt the referral will be closed.

    Your data will be kept in accordance with the General Data Protection Regulation (GDPR) (EU) 2016/679. This will be held securely and confidentially. Aiming Higher is registered with the Information Commissioners Office (Reg No ZA187596)

    Attached resources

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    For information on the services we can provide you with as a family, young person or carer. Click here.

    What we do

    I’m a professional

    For information on how to refer families to us and how we can support please click here.

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    Get Involved

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