The MAZE Parenting Programme: Booking Form - Video Series
The MAZE Parenting Programme is a structured specialist 12-week programme for parents/carers of children and young people with any kind of additional needs (with or without a diagnosis).

This booking form is to gather information about those who will be attending MAZE. This includes how you heard about MAZE. We are required under our funding agreement to collect certain information.  We also collect this information so we can understand your current needs and the level of support you are currently receiving. All the information is held confidentially.

Thank you for taking the time to complete this form! If you should have any further questions about anything in the form, or how this data will be used and stored, do not hesitate to get in touch.
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Name of person completing form *
Date Form Completed *
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DD
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Parent / Carer 1 Details
Title *
Name *
Relationship to Child / Children *
Email Address *
Mobile / Telephone Number *
Post Code *
Address *
Name of GP Practice *
Address of GP Practice *
Post Code of GP Practice *
Parent / Carer 2 Details
Title
Clear selection
Name
Relationship to Child / Children
Clear selection
Email Address
Mobile / Telephone Number
Post Code
Address
Name of GP Practice
Address of GP Practice
Post Code of GP Practice
Child / Children's Details
Name of Child / Young Person (1) *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Child's School *
Additional Needs (please specify) *
Required
Is your child or young person's additional need diagnosed? *
What level of SEND support is the child receiving *
Name of Child / Young Person (2)
Gender
Clear selection
Date of Birth
MM
/
DD
/
YYYY
Child's School
Additional Needs (please specify)
Is your child or young person's additional need diagnosed?
Clear selection
What level of SEND support is the child receiving
Clear selection
Name of Child / Young Person (3)
Gender
Clear selection
Date of Birth
MM
/
DD
/
YYYY
Child's School
Additional Needs (please specify)
Is your child or young person's additional need diagnosed?
Clear selection
What level of SEND support is the child receiving
Clear selection
Where did you hear about the MAZE Group? *
Name of Referrer (if not self-referral)
Organisation of Referrer (if not self-referral)
Referrer's Email Address (if not self-referral)
Referrer's Mobile / Telephone Number (if not self-referral)
Any other agencies involved?  (e.g., Social Care, EWMHS, Family Solutions, etc.)
Any Additional Information
Terms & Conditions
1. Accessing our Services
Applications to access The MAZE Group Parenting Programme are through referrals and are considered on completion of a booking form.  
The MAZE Group will make contact to acknowledge the booking form within 7 days and where applicable arrange for payment of the Programme. They will also request completion of a Pre-Programme Questionnaire.
Once payment has been received and the Questionnaire completed, The MAZE Group will provide login details to access the videos.
Videos are set with a 6-month expiry date and are non-downloadable.  
Sharing of these videos is not prohibited.
Under the terms of our funding, we must obtain certain information; this includes your child or young person's gender, date of birth, current school setting, details of your GP surgery and where you currently are on the Neurodevelopmental Pathway.  If this information is not provided then unfortunately we are not able to offer you access to the Programme.

2. Fees
All parents/carers whose GPs are located in North-East Essex are able to access the Programme at no cost due to funding from North-East Essex’s Clinical Commissioning Group.  For those outside of North-East Essex there is a nominal fee of £25.  

3. Prior to and Completion of our Programme
Prior to attending our Programme you will be asked to complete a questionnaire.  Access to the video content is provided on completion of the Pre-Programme Questionnaire which will be sent you within 7 days of a booking form being submitted. 
On completion of the Programme, The MAZE Group would be grateful for an evaluation form to be completed.  Under the terms of our funding, we are required to obtain feedback from attendees of our Programme.  

Please tick this box to confirm that you have read and understood The MAZE Group CiC's Terms & Conditions *
Required
MAZE Monthly Newsletter - on receipt of your referral form we will automatically register you to receive our monthly newsletter.  This is to enable you to receive updates, events and resources.  Please tick the relevant box below to give or refuse consent.
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Privacy Policy
The MAZE Group CiC takes data protection and confidentiality very seriously, and complies with the Data Protection Act 1998.  They are committed to ensuring that all personal data is stored securely, and will not be passed on to third parties unless instructed to do so.  Please refer to our Privacy Policy on the website for full details on the data we collect, store and process: https://www.themazegroup.co.uk/wp-content/uploads/2019/09/MAZE-Privacy-Notice.pdf
Please tick this box to confirm that you have read and understood how The MAZE Group CiC collects, stores and processes your personal data. You can withdraw your consent at any time by emailing amanda.towns@themazegroup.co.uk.  Please note that withdrawing consent may result in your place being withdrawn on the Programme. *
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