HAPii Referral Form for Independent Access Assessment

Referral Submitted

Thank you — your referral has been received by the HAPii team.
We will be in touch at the email address provided shortly.

Date of Referral

Date of Referral *

Referring Professional

Name *

Role *

Agency / Organisation *

Phone *

Email *

Child Details

Child Name *

Date of Birth *

Gender *

Family Details

Birth Parent Name 1 *

Birth Parent Name 2

Foster Carer Name 1

Foster Carer Name 2

Current Placement *

Referral Background

Reason for Referral *

Current Access Arrangements (if any)

Known Risks / Safeguarding Issues *

Relevant History

Attachments Enclosed

Court Order / Direction Existing Reports Consent Forms Other

Requested Service

Full Independent Access Assessment €2,400 approx + travel Other Please specify below

If other, please state

Additional Notes

Confirmation & Signature

I confirm that I have authority to make this referral and that all necessary consents are in place or will be obtained prior to assessment commencing.

Signature (Full Name) *

Date *