Skip to main content
Skip to navigation
Skip to accessibility tools
Feeling Unwell?
Search bar
Mobile navigation
What are you looking for today?
Close search
Home
Patients and visitors
Patients and visitors
Return to previous menu
Patients and visitors
Our Hospitals
Patient Experience
Getting to hospital
Getting to hospital
Return to previous menu
Getting to hospital
Blackpool Victoria Map
Clifton Hospital Map
Help with travel costs
Parking
Parking
Return to previous menu
Parking
Terms and Conditions
Patient Transport Services
While You're With Us
While You're With Us
Return to previous menu
While You're With Us
Eating and shopping
Safety and Security
Telephone directory
Visiting
Wifi
Patient Bedside Folders
Staff uniforms and their roles
Keep well in hospital
What to bring for your hospital stay
Getting home from hospital
Getting home from hospital
Return to previous menu
Getting home from hospital
Discharge information
Information for Carers
Once You're Home
What is stopping you from going home?
Outpatient appointments
Concerns and Complaints
Overseas Visitors
Patient Information Leaflets
Waiting Times
PEP+ managing waiting lists
Medications
Services
About us
About us
Return to previous menu
About us
Meet the Board
Meet the Board
Return to previous menu
Meet the Board
Board Meetings in Public
Organisational Structure
Membership and Governors
Reports and Publications
Our Values and Strategy
Equality Diversity and Inclusion
Freedom to Speak Up
Information Governance
Latest News
Patient Safety
Awards and Accreditations
Organisational Health Literacy
Work here
Work here
Return to previous menu
Work here
BTEC Work Experience Programme
BTH School Careers Programme
Care Experienced
Care Leaver Covenant
Careers at BTH
Career Change
Clinical Education
Exploring Healthcare Assistant Roles
Health Academy
Living and working on the Fylde coast
Our Partners
Parents & Guardians
Project SEARCH
Staff Benefits
T Levels
Thinking About Your Future
Training Provider Partners
Careers Web Resources
Work in Community
Work Experience
Vacancies
Apprenticeships
Not in Education, Employment or Training (NEET)
People Plan
Career Progression
Medical Education
Medical Education
Return to previous menu
Medical Education
Foundation Year Training
Specialty Training
General Practice Specialty Training
International Medical Graduates
Support us
Support us
Return to previous menu
Support us
Blue Skies Trust Charity
Volunteering
Get in touch
PaIRs self-referral form
Home
Services
Parent and Infant Relationship
PaIRs self-referral form
Parent/Caregiver First name*
Required
Parent/Caregiver Surname
Required
Date of Birth
Required
Date
Your Address
Required
Address 1
Address 2
City
Country
Select a country
United Kingdom
County
Postal Code
Contact number
Required
Can we leave a voice mail on this number
Required
Yes
No
Can we send text messages to this number
Required
Yes
No
Baby/child first name (if born)
Baby/child surname
Required
Baby/child Date of Birth (or Estimated Due Date)
Required
Date
GP Surgery name
GP phone number
We work closely with other services and professionals and may need to contact them in order to ensure we work together to get you the most appropriate support. Please list the services/ professionals you are involved with.
Do you consent to us contacting these services for more information to help us decide on the best support for you?
Yes
No
Reason for Requesting support from PaIRS
Required
Do you require any adaptations to meet your needs e.g. interpreter, sign language, or any neurodiversity adjustments?
Please tick the box below to confirm you consent to this referral. (Please note that we can only accept this form if the person has consented).
Required
Yes I consent to this referral.
Privacy policy
Required
I agree to the
privacy policy
Submit
You might also be interested in
...
About us
Latest News
Our Services
Accessibility tools
Show
accessibility tools
Text size:
Increase text size
Decrease text size
Reset text size
Contrast:
Black and white
Blue contrast
Beige contrast
High contrast
Reset contrast
Website created by
Frank Ltd.
Return to header
