Self-Funded Support Request Form

This form is for families who live outside Gloucestershire, or families who are self-funding their advocacy. If this is your situation then we request an initial agreement to fund 5 hours at a rate between £49 and £65 an hour, depending on the support needed plus a set-up fee of £25. This cost will be agreed with you in advance and is on the basis that any unspent money would be refunded. Depending on the complexity of the case there may be a need for additional funds, but that is agreed with you before any additional hours are worked.

The advice will be provided in accordance with the Service agreement and Terms and Conditions

ONLY fill in this form if you are happy to proceed in agreement with the service agreement and Terms and Conditions. 

Your Details

Please give us some details of your concerns. Please include as much detail as you can about why you need support and we will arrange for someone with the relevant skills to get in touch with you to find out more.

It would be useful to know what additional needs your child/young person has, what service(s) (e.g. education, social care etc.) are of concern and the type of issues that you have - failure to discuss/assess needs, failure to provide agreed needs, etc.