Community paediatrics referral form

Please note, once you’ve started this form you will be unable to save it until it is completed.

Details of the referrer

Name(Required)

Firstname Surname

Role(Required)

Agency/organisation(Required)

Address(Required)

Address line 1 Address line 2 Town County Postcode

Email(Required)

Phone(Required)

Child's details

Name(Required)

Firstname Surname

Date of birth(Required)

NHS number

Gender(Required)

Male
Female

Ethnicity(Required)

Other, please specify

First (or main) language(Required)

Address(Required)

Address line 1 Address line 2 Town County Postcode

Name of parent/guardian giving consent for referral and gathering information to support the referral(Required)

Relationship(Required)

Parent/guardian details

Name(Required)

Firstname Surname

Phone(Required)

Relationship to child(Required)

People who hold parental responsibility(Required)

Email(Required)

Mobile(Required)

First (or main) language(Required)

Is an interpreter required?(Required)

Yes
No

Preferred method of contact (please tick all relevant)(Required)

Text
Email
Phone

If there is a voicemail are they happy for us to leave a message?(Required)

Yes
No

GP details

Name(Required)

Name

Phone

Secure email

Address(Required)

Address line 1 Address line 2 Town County Postcode

School/nursery details

In school or nursery?(Required)

Yes
No

Name of school/nursery(Required)

Phone(Required)

Name of SENCO(Required)

Email to be used to send information pertaining to the report and potential medical reports(Required)

Address(Required)

Address line 1 Address line 2 Town County Postcode

Other professions involved(Required)

Please specify(Required)

Safeguarding

Are there any safeguarding concerns for this child?(Required)

Yes
No

Please detail(Required)

Is the child known to social services?(Required)

Yes
No

Please detail social worker(Required)

Is this child a Child in Need?(Required)

Yes
No

Is a Child Protection Plan in place for this child?(Required)

Yes
No

Is this a Looked After Child?(Required)

Yes
No

Local authority with responsibility(Required)

Is this child known to Early Help?(Required)

Yes
No

Is this child known to the Children’s Disabled Team?(Required)

Yes
No

Is this a child of armed forces personnel?(Required)

Yes
No

Referral

Reason for referral(Required)

Please describe clearly your current concerns and highlight any risk factors that you are aware of:
Please comment on the nature of the difficulties, onset, frequency and duration of these:

Do you require assessment for any of the following

Developmental delay/ impairment
Physical disability such as cerebral palsy

Do you require specific assessment for any of the following

Concerns with attention, fidgeting, impulsiveness and or hyperactivity/ suspected ADHD (we only accept referrals for children requiring an ADHD assessment who are 6 years and over)
Social communication difficulties/ suspected ASD

Please upload SNAP IV parent and SNAP IV teacher forms(Required)

Drop files here or

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

Is this child under 11 years of age?(Required)

Yes
No

We are unable to process this referral for neuro developmental assessment, please refer to https://www.nelft.nhs.uk/nlds.

Screening questionnaires will be sought after the referral is made.

Please detail any known diagnoses and any current medication(Required)

Please describe the child’s behaviour, development and social interactions and consider how your current concerns impact on the child’s wellbeing(Required)

Information on interventions already undertaken for example(Required)

(LIFT no. sessions/BEAMS/Early Help/Clever fingers etc.)

Social and family history(Required)

Please include family structure and any engagement with other professionals - HV/Early Help etc.
Please consider any significant life events/traumatic experiences, for example, divorce/separation, bereavement, domestic violence, drug/alcohol misuse and any parental mental ill health.

Child’s outcomes(Required)

Please give details of what the parent/carer would like to happen as a result of this request for support.

Referrer outcomes(Required)

As the referrer what outcomes are you anticipating for this child and their family?

Please print your name to confirm you are submitting this form with all completed information

Date(Required)

Supplementary information to support the referral

Please attach the Background information sheet(Required)

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

Please attach the School/nursery report (if in school or nursery)(Required)

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

Related forms

Background information sheet
Nursery - school report
SNAP IV questionnaires are only for use for children over six years
- SNAP IV parent ADHD screening tool
- SNAP IV teacher ADHD screening tool
Sleep diary and questionnaire

If any of the following are available, please also attach

These are not forms we provide.

- Cognitive assessments
- Educational psychology reports
- Dyslexia reports
- Therapy assessments
- Previous paediatric reports
- Private assessments/reports

Drop files here or

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

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Community paediatrics referral form

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