Short Breaks Referral Form

Sense’s short breaks are commissioned by Birmingham City Council as part of their short breaks offer and are open to any disabled child entitled to this offer. Our breaks allow children and young people to have fun, make friends and do things they enjoy in a safe and supportive environment. We provide tailored support to ensure each young person has the break they want, in a safe and supportive environment. Sense can provide highly specialist support particularly for children with multiple disabilities, specialist communication needs and medical needs, and can offer any young person an enjoyable holiday focused on what they want and need.

Children referred to our short breaks will be entitled to two short breaks across a year usually lasting 5 days. If you have any questions or want to find out more before making a referral please get in touch:

Martyn Dunn

Short Breaks Coordinator

/ 0207 520 0962

Contact Details
Name of child/young person:
Date of Birth: / Age:
Address:
Parents name:
Contact Details: / Tel No:
Mobile No:
Email:
Language/s Spoken:
(Please indicate if the families’ first language isn’t English & if an interpreter may be required.)
Do they receive a short break from elsewhere?
Referrer contact details (we will contact you to discuss your referral prior to making contact with the family)
Name of Referrer:
Relationship to Child:
Contact Details / Tel No:
Mobile No:
Email:
What is the best way for our coordinator to contact you?
Abilities & Disabilities
Please describe the child/young person’s abilities & disabilities:
Do they have a learning difficulty:
Not at all
¨ / Moderately
¨ / Severely
¨ / Profoundly
¨ / Not easily assessed
¨
Do they have a hearing loss:
No Loss
¨ / Mild Loss
¨ / Moderate Loss
¨ / Severe Loss
¨ / Profound Loss
¨ / Unknown
¨
Please describe their hearing loss:
Do they have a visual impairment? If so please describe here.
Other: (please include anything else that you think it is important we should know when considering your referral)

Please return the completed form to Martyn Dunn:

Email:

By Post: Holidays Team, Sense, 101 Pentonville Road, London, N1 9LG

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