ARCHIE GEORGE FOUNDATION
PROFESSIONAL REFERRAL SCREENING FORM - PLAIN TEXT VERSION
Professionals only. Families can self-refer by email without this form.
Save this file, enter your answers, and email it to referrals@archie-georgefoundation.co.uk.
Privacy notice: https://archie-georgefoundation.co.uk/privacy

1. REFERRING PROFESSIONAL
Professional name:
Role / job title:
Organisation:
Professional email:
Professional telephone:

2. CHILD OR YOUNG ADULT WHO NEEDS SUPPORT
Name:
Age in years:
Sex (optional; Prefer not to say is accepted):
Ethnicity (optional / self-described):
Disabilities / conditions / support needs (brief summary):

3. PARENT, CARER OR GUARDIAN
Name (or not applicable):
Relationship to child / young adult:
Safe contact details / preferred contact method (if agreed):

4. HELP REQUESTED (mark each relevant option with X)
[ ] EHCP / education-plan support
[ ] Applying for a Max Card
[ ] Applying for a grant
[ ] Finding suitable support or services
[ ] General chat / navigating the system
[ ] Other help

What is needed, and what support has already been tried?

Communication / accessibility needs and relevant dates (if any):

5. PERMISSION AND PROFESSIONAL DECLARATION
[ ] I have explained the referral to the person / family and confirmed appropriate permission or authority to refer.
[ ] I confirm explicit, informed consent has been obtained and recorded for sharing and using any health, disability or ethnicity information supplied for this referral.
[ ] I have shared the privacy notice, including retention periods and safeguarding limits to confidentiality, and included only relevant information.

Professional declaration - typed name:
Date:

Sex and ethnicity are optional; omitting them does not prevent a referral.
If consent is not available, contact us to agree the appropriate referral route before sending sensitive details.
This is not an emergency form: call 999 for immediate danger. The inbox is not continuously monitored.
Version 1 | 13 October 2026