Community paediatrician • General Practitioner (GP) • Allocated Nursing Specialist • School SENCO • Class Teacher • Social Worker • Any other registered professional: Professional Details Name of professional: Address: Professional role: Postcode: Relationship to child/young person: I confirm that the child/young person named in this application: Is aged between 0 18 years old (services extend to age 19 when young people remain in – special school post 18) within the Nottingham City boundary Has a diagnosed/identified disability from a qualified medical/clinical professional Is not able to access universal or targeted services without specialist 1:1 support (for further information on universal/targeted services please refer to the supporting guidance document) Name: Signature: Date: Finally, please make sure you have included the following information when submitting the form: Evidence of diagnosed/identified disability from a qualified clinical professional I have attached a copy of a covering letter from a professional A copy of the applicant’s current assessment (if applying for Pathway 2) Once completed this form should be returned (along with a covering letter from a professional, evidence of a diagnosed disability and a copy of the applicant’s current assessment). Either by email to or by post, addressed as follows: Private
• Community paediatrician • General Practitioner (GP) • Allocated Nursing Specialist • School SENCO • Class Teacher • Social Worker Any other registered professional: Professional Details Name of professional: Address: Professional role: Postcode: Relationship to child/young person: I confirm that the child/young person named in this application: Is aged between 0 – 18 years old (services extend to age 19 when young people remain in special school post 18) within the Nottingham City boundary Has a diagnosed/identified disability from a qualified medical/clinical professional Is not able to access universal or targeted services without specialist 1:1 support (for further information on universal/targeted services please refer to the supporting guidance document) Name: Signature: Date: Finally, please make sure you have included the following information when submitting the form: Evidence of diagnosed/identified disability from a qualified clinical professional I have attached a copy of a covering letter from a professional A copy of the applicant’s current assessment (if applying for Pathway 2) Once completed this form should be returned (along with a covering letter from a professional, evidence of a diagnosed disability and a copy of the applicant’s current assessment). Either by email to or by post, addressed as follows: Private
new_short_breaks_application_form_-_oct_2016.docx