Parent/carer referral
Child/young person details Date of birth(Required) Child/young person address(Required)
Child/young person GP address(Required)
Referrer details Is your address same as the child/young person?(Required) Your address(Required)
Do you give consent to receiving text reminders for appointments as appropriate? Do you consent to receiving correspondence by email? Do you have parental responsibility?
Reason for referral Hidden
INACTIVE Is the referral for Ready Steady Go? Before commencing on a Ready, Steady, Go programme a member of the School Health Service will contact you to complete a pre-assessment. You may be asked to see your GP or Paediatrician for further assessment if deemed necessary prior to commencing the programme.
Concerns(Required) What is happening with the child/young person that concerns you?
Strengths(Required) What supportive measures have been tried or are in place?
Is there any additional information you like to tell us about? (For example, family, friendships, school)
Desired outcome of the referral(Required)
Questions about the child Is this child/young person a young carer?(Required) Please give details(Required)
Is the child/young person a Looked After Child?(Required) Is an Education Health Care Plan in place?(Required) Are other agencies involved?(Required) Please give details(Required)
What agency and how were they involved?(Required)
Has the child/young person received any previous counselling/therapeutic interventions?(Required) What was the outcome?(Required)
Are there any safeguarding concerns?(Required) Have you discussed this with any other agency and what actions have been taken?(Required)
Information sharing agreement
Referral consent You will need to show the legal basis for referring this parent / carer / young person (KCHFT will not process your referral unless you indicate which applies below):
Article 6 (1) of the General Data Protection Regulation:(Required) Parent/carer consent obtained(Required)
We cannot accept any referrals without consent from the parent/carer or young person (where appropriate).
Confirmed parent/carer have parental responsibility(Required) Has child/young person consented for parents/carers to be informed of this referral?(Required) Why has the child/young person not given consent?(Required)
How this information was gained?(Required)
Referral details
Child/young person details
Date of birth(Required) Child/young person address(Required)
Child/young person GP address(Required)
Parent/carer details Is their address the same as the child/young person?(Required) Parent/carer address(Required)
Does parent/carer consent to receiving text reminders for appointments as appropriate? Any additional information
Reason for referral Hidden
INACTIVE Is this referral for Ready Steady Go? Does the child have... If you answer yes to any of the above please give details. Please be aware the programme includes physical activity and further assessment may be required. If you are a GP or Paediatrician, please indicate that you have assessed suitability to take part in the programme in light of tier 2 criteria.
Is there any more information regarding Healthy Habits that you would like to tell us about? For example, height cm (if measured), weight kg (if measured) and date measurement taken.
Concerns(Required) What is happening with the child or young person that concerns you?
Strengths(Required) What supportive measures have been tried or are in place?
Desired outcome of the referral(Required)
Questions about the child/young person These questions aren't needed for a Ready Steady Go referral.
Is this child/young person a young carer?(Required) Please detail caring responsibilities(Required)
Is the child/young person a looked after child? Is an Education Health Care Plan in place?(Required) Please give details(Required)
Are other agencies involved?(Required) Please specify which agency and why they are involved?(Required)
Are there any safeguarding concerns?(Required) Please specify safeguarding concerns(Required)
Have you sought advice regarding these concerns?(Required) From who and what actions have you taken?(Required)
Why haven't you sought advice?(Required)
Has this been referred to social services?(Required) Date referred(Required) Has a referral been made to Early Help?(Required) Date completed(Required) Has the child/young person/family been assessed by Early Help?(Required) What were the interventions and outcomes?(Required)
Referrer details Address(Required)
Information sharing agreement
Request for attendance at transition event Time of transition event(Required)
Request for Primary School health promotion event Please evidence from your school health profile how this health promotion event will support your school health action plan(Required)
Please evidence how this health promotion event will fit with your planned RSHE programme and published policy(Required)
Please note that use of visitors should be to enhance teaching by an appropriate member of your teaching staff rather than as a replacement by those teaching staff.
Health Visiting transition Date of birth(Required) Address(Required)
A referral can not be made without parent/carer (s) knowledge. Please confirm how the parent/carer(s) was informed(Required) Criteria for handover Please tick all boxes that apply.
Summary of health visiting intervention
Details of other agencies involved including names and contact details.(Required) For example, social services. Including named practitioner and their email address and phone number. Please write none if no agency involvement.
Article 6 (1) of the General Data Protection Regulation:(Required)
Referring agency details
Young person details Date of birth(Required) Contact address(Required)
How would the young person like us to contact them?(Required) GP address(Required)
Hidden
OLD INACTIVE Are social care involved? Hidden
OLD INACTIVE Multi-agency involvement? Organsation and practitioner.
Referral reason Desired outcome of the referral(Required)
Questions about the young person Is this child/young person a young carer?(Required) Please detail caring responsibilities(Required)
Is the child/young person a looked after child?(Required) Is an Education Health Care Plan in place?(Required) Please give details(Required)
Are other agencies involved?(Required) Please specify which agency and why they are involved?(Required)
Are there any safeguarding concerns?(Required) Please specify safeguarding concerns(Required)
Have you sought advice regarding these concerns?(Required) Has a referral been made to Early Help?(Required) Has the child/young person/family been assessed by Early Help?(Required) What were the interventions and outcomes?(Required)
Consent Young person consent obtained? Without this we will not be able to support you with your concern.
Has the young person consented to their parents/carers being informed of the referral?(Required) If No – why has the young person not given consent?(Required)
Parent/carers contact details(Required)