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Parent application form (for inclusion in the E-SEE study)
Details of the person with main parental responsibility
The following questions refer to the person with main parental responsibility
*
Your answer
Family name *
Your answer
First language *
Your answer
Interpreter required *
Home telephone *
Your answer
Mobile phone
Your answer
What is the best time to contact you? *
Your answer
Email address
Your answer
How would you prefer to be contacted? *
Required
Where did you hear about the study? *
Your answer
Address and Postcode *
Your answer
Your relationship to child *
Your answer
Is parental responsibility shared? *
If yes, state the relationship of that person to the child
Your answer
Would you be willing to give/send the co-parent a form similar to this one?
Details of the child
The following questions refer to the child
First name *
Your answer
Family name *
Your answer
Date of birth (or baby's due date) *
MM
/
DD
/
YYYY
Gender *
Address and postcode of child (if different to above)
Your answer
Details about any disability or diagnosis
Your answer
Consent to pass your contact details on to the research team
Please read each of the statements below, and tick each box if you agree
I confirm my child is less than 8 weeks old (or not yet born)
I agree that my contact details can be forwarded to a researcher at the University of York with the possibility of being invited to participate in the E-SEE study
I understand that a member of the research team may contact me with more details of the project and to discuss my possible participation in the research
I am aware that I am not obliged to take part in the study and I understand that my details will be protected and stored securely
I have been given a brief information leaflet about this study
Details of professional completing form with the family (not applicable if making self referral)
The following questions refer to the professional completing the form (if applicable)
Name
Your answer
Role/job title
Your answer
Organisation/agency
Your answer
Telephone number
Your answer
Email address
Your answer
Date form completed
Your answer
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