Local Offer Request form

Derby City Council would like to make the information that you have provided about your service available to members of the public, professionals that work with families, and services which parents use.

We will treat all information provided in confidence and in accordance with our privacy notice.

The fields marked with an asterisk (*) are required fields. All the information you enter will be submitted securely.

* Provider name

* Address where activity takes place

Contact details for public enquires

Name

Tel. No (No spaces)

Mobile (if appropriate)

Email

Confirm Email

Email addresses do not match.

Website

Correspondence details - we need this information to contact you to check the above details are up to date, they will not appear on our website

* Contact name

* Address

* Tel. No. (No spaces)

* Email

* Confirm Email

Email addresses do not match.

Services

* Please provide a description of the services that you provide.

For each service, please include details such as:

• Activity name
• Age range
• Cost
• Description of the service

* Service Availability

Please select All Year School holidays Term time only

Opening Times

* Monday

* Tuesday

* Wednesday

* Thursday

* Friday

* Saturday

* Sunday

Referral route for service

* Referral route for service

Application form via school
Attendance by professional referral
Drop in
Self referral

Service Eligibility

* Service Eligibility

Available To All - A Universal Service
Available To Anyone With A Difficulty Or Disability
Available To People Social
Emotional And Mental Heath Needs
Available To People With A Hearing Impairment
Available To People With A Moderate Learning Difficulty
Available To People With A Physical Disability
Available To People With A Profound Learning Difficulty
Available To People With A Severe Learning Difficulty
Available To People With A Specific Learning Difficulty
Available To People With A Visual Impairment
Available To People With An Autism Spectrum Disorder
Available To People With Behaviour
Emotional And Social Difficulty
Available To People With Speech
Language And Communications Needs
Only Available To Pupils Of The School

* Is your service aimed at children / young people with a particular need?

Yes
No

* Please state the particular need/s

Attention Deficit Hyper Activity Disorder
Autistic Spectrum
Challenging behaviours
Complex health needs
Mental health needs
Language / communication needs
Learning difficulties
Learning disabilities
Mult sensory impairment
Physical impairment
Visual impairment
Deafness
Other (please specify below)

If other, please specify