If you are a parent struggling to cope and would like our support, please complete the self-referral form below.

There is another form for Professional Referrals which can be located here: Professional Referral Form. Many of the fields in this form are optional, some fields are mandatory. If the field has an asterisk beside the description of the field you have to put some information in the field before submitting the form.

It is possible to temporarily save this form if you find you do not have all of the information available. You can return to the website and continue editing the form provided you use the same computer and browser. Any saved forms will be automatically removed from the server after seven days. The form is only sent to Home-Start West Berkshire when you click on the SUBMIT button. 

If you encounter any problems using this form, please contact us on the following number: 01635 760310.  When you have completed the form click on the submit button at the bottom of the form. When a form is submitted you will be taken to a “Thank You” page to confirm that the application was sent successfully.

Self Referral Form

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