Name of Individual: Date of Birth: Address of current placement: Current placement telephone: Gender: Ethnicity: Nearest Relative: Telephone: Clear, proven diagnosis of Learning Disablity?: Yes
No IQ score (if known): Is individual detained under Mental Health Act?: Yes
No Referrer's name: Telephone: Referrer's Email: Status of referrer: Funding authority: Reason for referral: Specific expected outcomes (clinical and social):