Contact us

SENDIASS is a self-referral service for families and we require the child/young person or the parent/carer to complete the following form.

If you are a practitioner, you may wish to support a young person/parent to complete this form or alternatively, contact us for general information and advice by email or phone.

Web Contact Form

1. Are you a child or young person? (required)
YesNo

If yes please go to Child / young person information.

If No please answer question 2.

2. Your Relationship to child (we can only accept referrals from the parent/carer or someone with parental responsibility).

3. Your name

4. Please let us know if you have any support needs of your own.

Child / Young person’s information:

5. Child/Young Person Name (required)

6. Child/Young Person Date of Birth (required)

If you are happy to, please tell us the child or young person’s ethnicity:

7. Ethnicity—Please choose an option—Prefer Not To SayWhite - Engl./Welsh/Scott./N.Irish/BritishWhite - IrishWhite Gypsy Or Irish TravellerWhite - Any Other WhiteMixed - White And Black CaribbeanMixed - White And Black AfricanMixed - White And AsianMixed - White And Any OtherAsian/Asian British - IndianAsian/Asian British - PakistaniAsian/Asian British - BangladeshiAsian/Asian British - ChineseAsian/Asian British Any OtherBlack/Black British - AfricanBlack/Black British - CaribbeanBlack/Black British Any OtherArabAny Other Ethnic Group

8. Postcode (required)

9. School (required)

10. Please select the main type of Special Educational Need or disability for the child/young person: (required)

—Please choose an option—Awaiting Diagnosis – on waiting listNo SENDOther not listedAnxiety / DepressionAttachment disorderADHD / ADDASD – Autistic Spectrum DisorderASD – Pathological Demand AvoidanceAuditory Processing DisorderBrain InjuryCerebral PalsyChronic Fatigue SyndromeDiabetesDown’s SyndromeDysgraphiaDyslexiaDyspraxiaDyscalculiaEpilepsyFoetal Alcohol DisorderGlobal Development DelayHearing ImpairmentLearning DifficultyLearning DisabilityLearning Disability – ModerateLearning Disability – SevereLearning Disability – Profound and MultipleObsessive Compulsive DisorderPhysical DisabilitySensory Processing DisorderSocial Communication DifficultiesSocial, Emotional and Behavioural DifficultiesSpecific Learning DifficultySpeech Language and communication NeedTourette's SyndromeVisual Impairment

11. Is there a SEN Support plan in place?

YesNoDon't Know

12. Is there an Education, Health and Care (EHC) plan in place?

YesNoDon't Know

13. In as much detail as possible, please explain how we can help you?

14. How would you like us to respond to you?

EmailPhone

15. Your email

16. Your Telephone Number

17. Where did you hear about our service? (please select option)

Used the service beforeSuffolk County CouncilEducation providerSENDIASS publicityFriend/family/parentHealth providerVoluntary, charity or community organisationOther - Specify below

17b. Other – please specify

18. I consent to the use and storage of my personal data by Suffolk Sendiass to enable them to provide information advice and support regarding my enquiries YesNo

19. I consent to the use and storage of my personal data by Suffolk Sendiass in order that I might receive newsletters and information about events, workshops and customer surveysYesNo