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 Does this child have an EHCP YesNo 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 All parents need to attend a webinar before a 1:1 referral is made I confirm the parent has already attended a webinar. I confirm this child will be actively supported by our service 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
