PRG Referral Form

*Important Update*

Due to the current situation with the Coronavirus Lockdown, we are unable accept any new referrals at this time. We have had to place our waiting list on hold. Any new referrals will not be contacted for an assessment appointment at this time. We will continue to assess the situation every couple of weeks. We apologise for any inconvenience.

If you have any questions about this form please contact the PRG Team on 01452 529866.

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Once this referral form is received we will contact you to arrange an initial assessment.

We are currently working through an influx of referrals. We anticipate waiting times to be longer than usual.

If you have any questions about this form please contact the PRG Team on 01452 529866.

Email address
Who is this referral for?
Agency details
Service user details
Risk Information

Splitz Support Service, Oak House, Epsom Square, White Horse Business Park, Trowbridge BA14 0XG
Registered Charity No: 1064764; Registered in England, Company Limited by Guarantee No: 3360057
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