Please confirm: *

Our Panoramic support is for children and families who have been affected by abuse and neglect. We work compassionately to provide wide ranging packages of meaningful long-term and therapeutic support, including: access to long term therapy, enrichment activities and support for parents/carers. Please only complete this form if you have consent to request support and share information on behalf of the child/family.

I am a professional making an enquiry for Panoramic Support on behalf of a family.

Name of professional making enquiry *

First Name

Last Name

Phone *

(###)

###

####

Please confirm which service you are enquiring about *

Panoramic Support (following abuse)

Letting The Future In (following sexual abuse)

Child's name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Child's ethnicity *

Asian or Asian British (Indian, Pakistani, Bangladeshi, Chinese, any other Asian background)

Black, Black British, Caribbean or African (Caribbean, African, any other Black, Black British, or Caribbean background)

Mixed or multiple ethnic groups (White and Black Caribbean, White and Black African, White and Asian, any other Mixed or multiple ethnic background)

White (English, Welsh, Scottish, Northern Irish or British, Irish)

White (Gypsy or Irish Traveller Roma, any other White background)

Other (Arab, Latino, any other ethnic group)

Prefer not to say

Unknown

Name of Parent/Carer

First Name

Last Name

Phone

(###)

###

####

Does the child have an EHCP?

Yes

No

Is the child entitled to pupil premium

Yes

No

Is the child entitled to free school meals?

Yes

No

Are the family facing financial hardship?

Yes

No

Is the child/family accessing

Universal services

Early Help/Targeted Services

S17 Child in Need

Child Protection Plan

Is the child a LAC/previous LAC?

No

LAC

SGO

Adopted

Before submitting this form, please ensure that you have read and agree to Cambridge Acorn Project’s Terms of Service and Data Protection (available at the bottom of this page) *

By submitting this form you are confirming that:

I confirm that parent(s)/Carer(s) have given consent to share their details with Cambridge Acorn Project and are aware that the information provided in this form will be safely stored and may be used to deliver services in response to this enquiry.

I confirm the form contains accurate information.

Yes, I have read and I agree to Cambridge Acorn Project's Terms of Services.

Submission date *

MM

DD

YYYY