Professional Support Form

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Professional Body Registration Details

Child/Young Person’s Details

DD/MM/YYYY

Please tell us about the child/young person’s condition/disability:

Newlife defines a significant disability as being a physical and/or cognitive impairment which affects activities of daily living. A life-threatening condition should be defined as a condition whereby the next period of ill health would make it likely that life sustaining intervention would be needed. Newlife defines a life-limiting condition as a condition that results in a shortened life expectancy, as opposed to having limited life experiences that could affect quality of life. A terminal illness is generally defined as not being expected to live longer than six months and/or a person who has an advanced care plan to meet end of life care needs.

For more information on GMFCS, call 0800 902 0095 for support to identify classification.

As an organisation that isn’t directly involved in the child’s care, a historical perspective of safeguarding concerns can be helpful when understanding the reason for this application.

Has the Child/Young Person received any of the following needs assessments?

For more information on these different types of holistic assessments that may precede an equipment assessment (or indeed trigger one) and a child/young person's legal rights to them, please call 0800 902 0095 for support.

Please note when answering this question whether the outcomes are short-term or long-term options for supporting the child/young person. E.g. are there plans to move home or adapt the property to meet the child/young person’s needs?

Please note: we would expect any measurements of the child, e.g. leg length, to be accounted for in the quote/specification.

If you are unable to name a specific make/model of equipment because of local practice/policy-based restrictions, please call 0800 902 0095 for support. Depending on the circumstances currently affecting the individual child, it may be that you can confirm that provision of the requested equipment is not likely to be detrimental to the child's safety, health and wellbeing.

Please answer these questions to demonstrate how the requested equipment will benefit the child/young person and their immediate family:

Newlife can provide emergency equipment loans to help mitigate any immediate and significant risks to a child/young person's health and safety. If these are identified above, by signing the declaration at the end of this form you are agreeing to review alternative specifications of equipment owned by Newlife that could protect the child/young person.

Professional Declaration

If you would like to know more about what we do, or help us in other ways that could help change the lives of disabled children and their families then please tick the boxes below. The permissions associated within this section refer to your details rather than anyone else referred to in the application:

If ‘Yes’, we will contact you initially to provide details about all of our Child and Family Support Services and then as we develop and update each individual service.

If ‘Yes’, we may be able to improve the likelihood of funding the equipment by appealing for support through your local press. You can expect the media team at Newlife to call you to discuss generating and sharing a media story about the child/young person’s need for the equipment and help provide funding for the equipment earlier than if it was not undertaken.

If ‘Yes’, we may be able to improve the likelihood of funding the equipment by appealing for support through your local press. You can expect the media team at Newlife to call you to discuss generating and sharing a media story about the child/young person’s need for the equipment and help provide funding for the equipment earlier than if it was not undertaken.

If ‘Yes’, there are many different ways we can support you to build up donations towards funding this equipment. Our fundraising team would be happy to share their experience with you and support any future fundraising activities.

If ‘Yes’, there are many different ways we can support you to build up donations towards funding this equipment. Our fundraising team would be happy to share their experience with you and support any future fundraising activities.

(name of supporting professional)

if you have any questions, please contact our care services for free on:

Phone-number0800 902 0095

www.newlifecharity.co.uk

Newlife Centre, Hemlock Way, Cannock, Staffordshire WS11 7GF. Newlife the Charity for Disabled Children - Registered Charity Number: 1170125 in England & Wales

We, Newlife the Charity for Disabled Children are the ‘controllers’ of the information which we collect about you. We are committed to protecting your personal data, whether it is sensitive or not, and we only process data if we need to for a specific purpose. We collect and process data to campaign locally and nationally on behalf of disabled, terminally ill children and their families. To see Newlife’s full Privacy notice, please visit http://newlifecharity.co.uk/docs/general/Resources-and-Documents.shtml