Trafford Sleep Services 1:1 Clinic Referal Contact Details Professional details Parent/Carer details Child details Child Date of Birth Does the Child have any additional needs? ADHDASDDiagnostic pathwayLearning difficulty/disorderPhysical difficulty/disorderSocial, Emotional and Mental Health DifficultyNone Type of sleep difficulty Settling to sleepNight wakingBed wetting (after the age of 5)Sleep TerrorsNightmaresEarly morning wakingNone Please discuss this referral with the parent and check they are in a position to work on their child’s sleep I confirm this referral has been discussed with parents YesNo Please confirm the following The parent has attended a webinar YesNo Does this child have an EHCP YesNo The child is being referred by a paediatrician YesNo The child attends one of the following specialist educational placements Brentwood School and CollegeDelamere SchoolLongford Park SchoolThe OrchardsPictor AcademyManor AcademyNone The child is under the care of the local authority (LAC) YesNo I agree to Sleep and Therapy Services processing my data for the provision of sleep services. Privacy notice is available at the bottom of the website. Contact us Get in touch Working together to transform children’s lives through Sleep and Therapy Services Email Address Trafford@sleepandtherapyservices.co.uk Email Phone number +44 7838110985 (Please get in touch by email as we are not always contactable by phone) Phone
