Referral form – local authorities

Please request a quote of our subsidised fixed rate. In certain circumstances, there may be legal aid available, please confirm whether you would wish for the young person to be assisted under legal aid or under PRCBC subsidised fixed rate.

IMPORTANT: Due to the nature of our legal advice and assistance, we are required to keep your data for a certain period.

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– Step 1 of 6

Name of Local Authority including contact details *

Full name of young person *

First

Last

Emergency contact person *

Phone

Email address *

Relationship to young person

Next

Address of young person

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Contact number

Email address *

Date of birth

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Age

Country of birth

Nationality

Ethnicity

Next

Date of arrival in the UK (if relevant)

Length of time living in the UK (if relevant)

Dates of any absence(s) from the UK since birth or since first arrival in the UK

Young person’s legal status in the UK

Date of grant of stay in the UK

Any medical/special needs

Details of any fine(s)/caution(s)/criminal conviction(s)

Next

Mother’s nationality

If British citizen, please confirm whether this is by birth, naturalisation or registration

• Birth
• Naturalisation
• Registration
• Not known

Date of registration or naturalisation

Mother’s status in the UK

Date of grant of status

If ILR/settled, date of grant

Next

Father’s nationality

If British citizen, confirm whether this is by birth, naturalisation or registration

• Birth
• Naturalisation
• Registration
• Not known

Date of registration or naturalisation

Father’s status in the UK

Date of grant of status

If ILR/settled, date of grant

Next

Are the child’s parents married to each other?

• Yes
• No

Date of marriage

Any urgent deadlines?

Brief details of advice being sought and/or any additional information

If possible and relevant, please attach copies of any status document/Home Office citizenship decision or any other relevant documents

Submit