BBA Enrolment Form » Voices of Hope

Referring hospital/organisation

Cambridge University Hospital Kingston Hospital Epsom & St Helier Hospitals Other:

Name of referring physiotherapist/clinician

Full names of the child being referred to the Big Breathing Adventure (BBA).

Date of Birth of the Child (DD/MM/YYYY):

What is the child's gender?

Female Male Prefer not to say

Full name(s) of parent(s)/carer(s) with parental responsibility

Relationship(s) to child

Parent's/carer's primary email address where you will be contacted regarding the BBA course.

Is your child confident in understanding spoken English?

Yes No Somewhat

Are you, the parent/carer, confident in understanding spoken and written English?

Yes No Somewhat

Does your child require any additional support to take part in group sessions (e.g., learning support, mobility support, sensory needs)?

Yes No Other:

Reason(s) for Referral (please tick all that apply)

Do you have any additional information you think we should know about your child?

To better support your child while on the Big Breathing Adventure (BBA) Course, information will be shared with their referring physiotherapist and/or hospital.

Yes: I’m happy for the BBA team to share relevant information about my child’s participation in BBA with the referring physiotherapist and/or hospital No: I prefer that the BBA team does not share information about my child’s BBA participation with the referring physiotherapist and/or hospital. Yes, with limits: I’m happy for information to be shared, with the following limits (please specify) Other: