Please complete the following form, if you require any assistance in completing the form, have any questions or require any further information please do not hesitate to contact me. Once you have completed this form please return by e-mail below.

Contact: Emma Walker

Telephone: 01244 973829

E-mail:

1)  Service Contact Details

Name of your service
Address
Contact Name
Telephone
Email
Website

2) What age range does your service cater for?

Age (from) / Age (to)

3) What are your opening times?

Opening Hours
Additional Opening times – (please include any further opening times/periods that are different from the opening times above eg. Service groups as part of your service etc..)

4) Cost, are there any costs involved in using your service?

If yes please indicate costs below

5) Referral – please let us know who you are able to receive referrals from and if your service can accept self referrals, please tick as applicable

Referral method / Please tick
(as applicable)
Self referral
Via CAMHS
Via GP or Health Professional
Via Housing Advice
Via Independent Living Team
Via Jobcentre Plus
Via School
Via Social Care
Via Voluntary Agencies
Via Youth Offending Team
Referral Procedure/other referral methods (please state)
Is there a waiting list to access your service?, if yes please indicate how long your waiting list is

6) Accessibility and communication - please indicate yes/give details /complete the other field as applicable

Accessibility / Please tick/provide details (as applicable)
Wheelchair access
Accessible toilet/changing facilities
Accessible Parking
Have there been improvements in the auditory and visual environment?
What support is there for a child/young person with additional needs in general areas eg. waiting rooms
Communication / Please indicate
tick/provide details (as applicable)
What are your usual methods for seeking the views of service users?
Do you use any specialist communication eg. Signing
How do you communicate with service users whose first language is not English?
Hearing loop
Text phone
Translated material
Large print material
Materials in Braille
Other (please state)

7) Please provide any keywords that you think would be useful to someone searching for your service

8) Please provide a description of your service, please include any information that you think may be useful to parents/carers, young people or other members of the public which may want to access your service.

9) How would someone be able to access your service please tick/complete the other field as applicable?

Method of access / Please tick (as applicable)
Email
Face to face
Online form
Outreach Service
Post
Telephone
Texting
Website
Other (please state

10) How do you deliver you service please tick/complete the other field as applicable?

Delivery of service / Please tick (as applicable)
Telephone
Helpline
Post
Email
Face to face
Outreach Services
Website Forum
Texting
Other (please state)

11) What area(s) in Cheshire West and Chester does your service cover? Please tick/complete the other field as applicable

Area / Please tick (as applicable)
All Areas of Cheshire West and Chester
Chester
Ellesmere Port
Neston
Winsford
Northwich
Frodsham and Helsby
Other (please state)

12) Are there any restrictions on eligibility for someone using your service?

13) Would you like to update your service information yourself, using our online form?

if yes, please provide the following:

Name of the person who will be updating your information:

E-mail address that you would like us to use to provide information eg. instructions/username and password

Please note: With regards to question 13, due to development of the directory this will not be available straight away.

Please note in completing this form, any feedback provided individually about your service will remain on the site for 6 months, you have the right to reply to any feedback posted, and no fictitious or malicious feedback will be published.

Thank you for taking the time to complete the following form

Many thanks

Emma Walker

Telephone: 01244 973829

E-mail:

Address: Ground Floor, 4 Civic Way, Ellesmere Port CH65 0BE

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