Breathe Magic Intensive Therapy Programme Child Referral Form

Breathe Magic Intensive Therapy Child Referral Form

Thank you for your interest in the Breathe Magic Intensive Therapy Programme.

Due to consent purposes, this form should be completed by a parent or guardian. Completing this form is the first step in expressing your interest to attend The Breathe Magic Intensive Therapy Programme. Once completed, you should expect to hear from one of Breathe’s Clinical Leads within two weeks. They will be able to provide guidance around the next steps in signing up to attend the programme as well as answer any questions you may have about the programme.

If you require any help completing this form or would like to receive it in a different format please contact us by email on info@breatheahr.org or telephone 020 3290 2013.

Please note: If you are a clinician looking to make a referral please get in touch with us directly on 020 3290 2013 or info@breatheahr.org or request that the parent/guardian completes the below form.

We look forward to hearing from you!

Fields marked with * are mandatory.

 

Personal Details

*Child’s Full Name:

*Child’s Date of Birth:

*Child’s Gender: (select from dropdown)

*Parent/Guardian’s Full Name:

*Email:

*Telephone 1:

Telephone 2:

*Street:
*City:
*Postcode:
*Country:

 

Eligibility
The following are our main eligibility criteria for young people attending Breathe Magic Camps, please tick as appropriate to confirm this applies to your child. Please be assured that a ‘no’ to any criterion doesn’t necessarily mean your child is ineligible. The answers you give should be your best estimate and will be used to inform the conversation with our Clinical Leads to inform whether the programme will be suitable for your child.

*Young person with hemiplegia – or one-sided weakness – caused by Cerebral Palsy or Acquired Brain Injury: (select from dropdown)
*Aged 7-19 years at start of camp: (select from dropdown)
*Able to remember sequences of 3-4 steps: (select from dropdown)
*Can cooperate to perform tasks in a group setting: (select from dropdown)
*Attending mainstream school: (select from dropdown)

How did you hear about the programme? (select from dropdown)

Would you like to sign up to our newsletter?
Yes, please sign me up.

 

Please let us know any further details relevant to your answers as well as the dates over Easter and Summer 2020 when you would be available. (Please do not include any medical details here) :

By submitting this form you are consenting to our privacy policy.