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TGP Cymru

North Wales Communication Passports Referral Form

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North Wales Communication Passports Referral Form

Please complete the below form to make your referral.

Please note: this form has multiple steps and you must complete them all in order to make your referral.

Step 1 of 2

50%

Section 1: Child/Young Person’s Personal Information
Name*
Date of birth*
DD slash MM slash YYYY
Full postal address*
Street Address Address Line 2 Address Line 3 ZIP / Postal Code
Telephone number
Mobile number
Gender
Legal status
Ethnicity
Welsh speaker
- Yes
- No
Physical/Learning Disability? If yes please specify:
Parent/Carer name and contact details*
Name of Child/Young Person’s Social Worker*
Local Authority Team Name*
Social Worker telephone number
Social Worker mobile number
Social Worker email address*

Section 2: Referral Information
Date of referral*
DD slash MM slash YYYY
Referred by*
Local Authority/Organisation*
Local Authority/Organisation contact details*
Is the child/young person aware of referral?*
- Yes
- No
Is the parent/carer aware of referral?*
- Yes
- No
Is the family/child/young person requesting a service?*
- Yes
- No
Please specify communication difficulties (if any)
Please provide information regarding how the young person communicates and how best to share information with him/her
Please provide additional relevant information
Does the child/young person need an Advocate?*
- Yes
- No
Does the child/young person need a Communication Passport?*
- Yes
- No
Does the child/young person need a One Page Profile?*
- Yes
- No
Referer's email address*

Referral reply will be sent to this address

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Head office

TGP Cymru
Cardiff University Social Science Research Park (SPARK)
spark
Maindy Road
Cardiff
CF24 4HQ

Living Wage Employer

TGP Cymru is the working name of Tros Gynnal Plant.
Registered Charity No. 1099878. Registered as a company limited by guarantee No. 04422485 (England & Wales).
Registered Office: Cardiff University Social Science Research Park (SPARK), spark, Maindy Road, Cardiff, CF24 4HQ – 02920396974
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