Sleep Tight Trafford referral form

Parent/Carer's name *

Email address *

Postcode

Telephone number

Your child's name *

Your child's gender

Your child's date of birth *

Year

Month

Day

Name of your child's school *

Does your child have an autism diagnosis or are they on the pathway? *

Yes they have an autism diagnosis

Yes they are on the pathway

No

Does your child have any additional diagnoses? (If yes, please state which) *

Is your child currently prescribed any sleep related medication? *

Does your child have any siblings that need sleep support? If yes, how many?)

If yes, please state the sibling's name, date of birth,details of any diagnosis, the name of their school school and if they have SEND or are on a pathway

How did you hear about the service