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-mailto

Where multiple choices – please select all indicators which apply to your service

1. Service Contact Details

Name of your service
Service Description

2. Where can I access the service?

Service Location Address
Service Location Postcode

3. Who can I contact to access the service?

Contact Name
Telephone
Email
Website
Facebook Page
Twitter Page

4. Is your service available in any of the following areas in St Helens?

Ward /  / Ward / 
Billinge & Seneley Green / Rainford
Blackbrook / Rainhill
Earlestown / Sutton
Eccleston / Thatto Heath
Haydock / Town Centre
Moss Bank / West Park
Parr / Windle

5. Is your service available in any of the following neighbouring Local Authority areas? …..

 / 
Halton / Wigan
Knowsley / Warrington
Liverpool / Manchester
National

6. What age groups does your service cater for?

Age Group / Tick as appropriate
0 - 25
0 - 2
2 - 3
3 - 4
4 - 5
5 - 7
8 - 11
12 - 15
16 - 18
18+

7. Does your service provide for children, young people, or adults with:

 / 
Complex Health Needs / Autistic Spectrum Conditions
Moderate Learning Difficulties / Social, Mental, Emotional Health issues
Severe Learning Difficulties / Visual Impairment
Profound and Multiple Learning Difficulties / Hearing Impairment
Specific Learning Difficulties / Challenging Behaviour
Physical Difficulties / Personal Care Needs
Speech, Language and Communication needs

8. Which of the following categories of service applies to your service?

 / 
Targeted Services / Universal Services
Specialist Services / Local Authority
Health / Education

9. Which of the following categories best describes your service?:

 / 
Educational Settings / Post-16 Education & Training
Early Years / Health Services
Social Care & Support Provider / Voluntary / Community Group
Transport / Housing Accommodation
Preparing for Adulthood (16-19) / Preparing for Adulthood (19-25)
Leisure & Recreation Services / Short Breaks
Respite Care / Information, Advice & Guidance

10. When is your service available?

Opening Hours
Day / Start Time / End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Additional Opening times – please indicate any exceptions to the standard opening hours

11. Do I have to pay to use your service?

Yes
No

If yes, please indicate costs below

12. How can I be referred to access your service?

 / 
Self Referral / Direct Access / Via Social Care
Via CAMHS / Via Voluntary Agencies
Via GP or Health Professional / Via Youth Offending Team
Via Housing Advice / Via Supported Living Team
Via Jobcentre Plus / Via School / College / Connexions
Other – Please Advise :

13. How would someone be able to access your service?

Method of access / Please indicate

Email
Face to face
Kiosk
Online form
One Stop Shops
Outreach Service
Post
Telephone
Texting
Website
Other (please state

14. Is there a waiting list to access your service?

Yes
No
If yes please give details

15. Can your service be delivered in the home or within the community?

Indicate
 / Please give details (as applicable)
Home
Community

16. Does your service have? …..

Indicate
 / Please give details(as applicable)
Transport service
Accessible Parking
Wheelchair access
Access Adaptations eg. Hand rails
Accessible waiting areas
Accessible toilets
Accessible changing facilities
Sensory Adaptations
Sensory Room
Soft Play facility
Not applicable

17. What methods of communication can you offer?

Communication / Indicate
 / Please give details (as applicable)
Makaton
British Sign Language
Assistance for service users whose first language is not English?
Hearing loop
Text phone
Translated material
Large print material
Materials in Braille
Other (please state)

18. Are there any restrictions on eligibility for someone using your service?

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

Going forward; if you would like to update your service information yourself, using our online form once it is available, please provide contact email address for notification that the service is available?

Name of the person who will be updating your information:

E-mail address that you would like us to use to provide information eg.

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