Are you a ...* Please select Parent/carer Professional
Are you making a...* Please select Referral Young person referral (for young people aged 13 and over) Request for attendance at transition event Request for Primary School health promotion event Health Visiting transition
Parent/carer referral Child/young person details Forename*
Surname*
Date of birth* Gender*
Ethnicity* Please select... White - British White - Irish White - Other Mixed - White and Black Caribbean Mixed - White and Black African Any other mixed* Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Any other Asian background* Black or Black British - Caribbean Black or Black British - African Any other Black background* Chinese or other Ethnic - Chinese Chinese or other Ethnic - Vietnamese Any other Ethnic group* Traveller community Decline to provide
Child's NHS number
Child/young person address*
Child/young person mobile number
School* Type to search for school... Home educated Not in education, training or employment Alfriston School All Saints And St Richards CE Primary School All Saints CE Junior Academy (Hastings) All Saints CE Primary School (Bexhill) Annecy Primary School Ark Blacklands Primary Academy Ark Castledown Primary School ARK Helenswood Academy Ark Little Ridge Primary Academy Ark Sixth Form ARK William Parker Academy Ashdown Primary Barcombe CE Primary School Battle and Langton CE Primary School Beacon Community College Academy Trust Beckley CE Primary School Bexhill Academy Bexhill Sixth Form College Blackboys CE Primary School Bodiam CE Primary School Bonners CE Primary School Bourne Primary School Breakwater Academy Brede Primary School Broad Oak Community Primary School Burfield Academy Burwash Church of England Prinmary School Buxted CE Primary School Catsfield Church of England Primary School Cavendish School Academy Trust Chailey School Chailey St Peter's CE Primary School Chantry Community Primary School Chiddingly Primary School Christ Church CE Primary School Churchwood Primary Academy Chyngton School Claverham Community College Cradle Hill Cross-in-Hand Church of England Primary School Crowhurst CE Primary School Cuckmere House, School, Seaford Dallington CE Primary School Danehill CE Primary School Denton Community Primary School and Nursery Ditchling (St Margaret's) CE Primary School Dudley Infant Academy East Sussex College Eastbourne East Sussex College Hastings East Sussex College Lewes East Hoathly CE Primary School Etchingham CE Primary School Firle CE Primary School Five Ashes Church of England Primary School Fletching CE Primary School Forest Row CE Primary School Framfield CE Primary School Frant Church of England Primary School Gildredge House Glenleigh Park Primary Academy Glyne Gap Academy Groombridge St Thomas' CE Primary School Grove Park Primary Grove Park Secondary Grovelands Community Primary School Guestling-Bradshaw CE Primary School Hailsham Community College Academy Trust Hamsey Community Primary School Hankham Primary School Harbour Primary and Nursery School Harlands Primary School Hawkes Farm Primary School Hazel Court Sixth Form Hazel Court Special School Heathfield Community College Hellingly Community Primary School Heron Park Primary Academy Herstmonceux Primary School High Cliff Academy High Hurstwood CE Primary School Hollington Primary Academy Holy Cross CE Primary School Hurst Green CE Primary School Icklesham CE Primary School Iford and Kingston CE Primary School Jarvis Brook Primary School King Offa Primary Academy Kings Academy Langney Primary School Laughton Community Primary School Little Common School Little Horsted CE Primary School Manor Primary School Mark Cross Church of England Primary School Mayfield Church of Engalnd Primary School Maynards Green Community Primary School Meridian Primary School Motcombe Community School Netherfield CE Primary School New Horizons Academy Newick CE Primary School Ninfield Church of England Primary School Northiam CE Primary School Nutley CE Primary School Oakwood Primary Academy Ocklynge Junior School Ore Village Primary Academy Park Mead Primary School Parkland Infant School Parkland Junior School Parkside Community Primary School Pashley Down Infant School Peacehaven Community School Peacehaven Heights Primary School Peasmarsh CE Primary School Pebsham Primary Academy Pevensey and Westham CE Primary School Phoenix Academy Plumpton College Plumpton Primary School Polegate Primary School Priory School Punnetts Town Community Primary School Ratton School Ringmer Primary School Ringmer Sixth Form Robertsbridge Community College Robsack Wood Primary Academy Rocks Park Primary School Roselands Infants' School Rotherfield Primary School Rye College Rye Primary Sacred Heart Catholic Primary School, Hastings Salehurst Church Of England Primary School Sandown Primary School Saxon Mount School Seaford Head School Seaford Primary School Seaford Sixth Form Seahaven Academy Sedlescombe CE Primary School Shinewater Primary School Silverdale Primary Academy Sir Henry Fermor CE Primary School South Malling CE Primary School Southover CE Primary School St Andrew's CE Infants School St Catherine's College St John's CE Primary School St John's Meads CE Primary School St Leonards CE Primary School St Mark's CE Primary School St Mary Magdalene's Catholic Primary School St Mary Star of the Sea Catholic Primary School St Mary the Virgin CE Primary School St Marys Catholic Primary School St Mary's Horam St Michael's CE Primary School St Michael's Primary School St Pancras Catholic Primary School St Paul's CE Primary School St Peter and St Paul Church of Engalnd Primary School St Phillip's Catholic Primary School St Thomas A Becket Catholic Infant School St Thomas A Becket Catholic Junior School St Thomas' Chuch of England Primary School St. Richards Catholic College Stafford Junior School Staplecross Methodist Primary School Stone Cross School Stonegate CE Primary School Telscombe Cliffs Community Primary School The Baird Primary Academy The Causeway School The Eastbourne Academy The Hastings Academy The Haven Voluntary Aided CofE/Methodist Primary School The Lindfield School The South Downs School The St Leonards Academy Ticehurst and Flimwell Tollgate Community Junior School Torfield School Uckfield Community Technical College, Sixth Form Uplands Community College UTC @ Harbourside Wadhurst Church of England Primary School Wallands Community Primary School West Rise Infants West Rise Junior School West St Leonards Primary Academy Western Road Community Primary School Westfield Primary School White House Academy Willingdon Community School Willingdon Primary School Wivelsfield Primary School Other
If other school, please specify
Year group
If applicable and for year 8 and above please ensure that you have the child’s consent to refer.
Child/young person GP name*
Child/young person GP address*
GP phone number*
Referrer details Your name*
Is your address same as the child/young person?* Your address*
Your phone number*
Do you give consent to receiving text reminders for appointments as appropriate? Your email*
Do you consent to receiving correspondence by email? Your relationship to the child/young person?
Do you have parental responsibility? Next of kin*
Parent two*
Parent one*
Reason for referral Reason for referral* Please select... Bowel and bladder 4-11 (primary aged children who have trouble with wetting and bowel issues) Healthy You 4-11 (primary aged children who have multiple difficulties i.e. sleep, diet, physical activity, gadgets and screen time, puberty, hygiene and growing up) Healthy Sleep 4-11 (primary aged children who have trouble settling at night or staying a sleep throughout the night) Emotional health and wellbeing 4-11 (primary aged children who need support with worries, feelings, friendships, coping mechanisms, self-care or self-esteem / confidence Henry Programme (an 8 week healthy lifestyle programme for families with children aged between five to 12 years focusing on helping families adopt a healthier lifestyle) Healthy You 11-19 (young people aged 11-19 to improve health and lifestyles i.e. relationships, sexual health, puberty, emotional health, substance misuse, smoking, sleep, eating, weight, exercise - enabling them to identify their own goals) Health care plan for long term conditions (support to schools with completing or reviewing a HCP) Hearing test (children and young people where there are concerns about their hearing) Targeted emotional health and wellbeing None of the above
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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* What is happening with the child/young person that concerns you?
Strengths* 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*
Questions about the child Is this child/young person a young carer?* Please give details*
Is the child/young person a Looked After Child?* If yes, please name social worker
Is an Education Health Care Plan in place?* Are other agencies involved?* Please give details*
What agency and how were they involved?*
Has the child/young person received any previous counselling/therapeutic interventions?* When did this intervention end?*
Who completed the intervention?*
What was the outcome?*
Are there any safeguarding concerns?* Have you discussed this with any other agency and what actions have been taken?*
Information sharing agreement The parent / carer / young person has been informed of the following:
Records are kept securely and confidentiality is respected in accordance with the Data Protection Act 2018 and the General Data Protection Regulation. We have a duty to refer to Social Services any child or adult who may be in need of protection.
Information will be shared and discussed between professionals and other agencies to help you/your child and family. You will be consulted following these discussions regarding any future planning and actions.
You understand that you have the right to object to my information being processed by Kent Community Health NHS Foundation Trust, but that this may result in the Trust not being able to treat you/your child or your family.
Signature* Date*
DD slash MM slash YYYY
Attachment(s)
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Professional referral 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:* Parent/carer consent obtained* We cannot accept any referrals without consent from the parent/carer or young person (where appropriate).
Confirmed parent/carer have parental responsibility* Has child/young person consented for parents/carers to be informed of this referral?*
Do not contact parent/carer without prior discussion with young person.
Why has the child/young person not given consent?*
How this information was gained?*
Referral details Child/young person details
Forename*
Surname*
Date of birth* Ethnicity* Please select... White - British White - Irish White - Other Mixed - White and Black Caribbean Mixed - White and Black African Any other mixed* Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Any other Asian background* Black or Black British - Caribbean Black or Black British - African Any other Black background* Chinese or other Ethnic - Chinese Chinese or other Ethnic - Vietnamese Any other Ethnic group* Traveller community Decline to provide
Gender*
NHS number
Child/young person address*
Child/young person phone number
(if applicable)
School* Type to search for school... Home educated Not in education, training or employment Alfriston School All Saints And St Richards CE Primary School All Saints CE Junior Academy (Hastings) All Saints CE Primary School (Bexhill) Annecy Primary School Ark Blacklands Primary Academy Ark Castledown Primary School ARK Helenswood Academy Ark Little Ridge Primary Academy Ark Sixth Form ARK William Parker Academy Ashdown Primary Barcombe CE Primary School Battle and Langton CE Primary School Beacon Community College Academy Trust Beckley CE Primary School Bexhill Academy Bexhill Sixth Form College Blackboys CE Primary School Bodiam CE Primary School Bonners CE Primary School Bourne Primary School Breakwater Academy Brede Primary School Broad Oak Community Primary School Burfield Academy Burwash Church of England Prinmary School Buxted CE Primary School Catsfield Church of England Primary School Cavendish School Academy Trust Chailey School Chailey St Peter's CE Primary School Chantry Community Primary School Chiddingly Primary School Christ Church CE Primary School Churchwood Primary Academy Chyngton School Claverham Community College Cradle Hill Cross-in-Hand Church of England Primary School Crowhurst CE Primary School Cuckmere House, School, Seaford Dallington CE Primary School Danehill CE Primary School Denton Community Primary School and Nursery Ditchling (St Margaret's) CE Primary School Dudley Infant Academy East Sussex College Eastbourne East Sussex College Hastings East Sussex College Lewes East Hoathly CE Primary School Etchingham CE Primary School Firle CE Primary School Five Ashes Church of England Primary School Fletching CE Primary School Forest Row CE Primary School Framfield CE Primary School Frant Church of England Primary School Gildredge House Glenleigh Park Primary Academy Glyne Gap Academy Groombridge St Thomas' CE Primary School Grove Park Primary Grove Park Secondary Grovelands Community Primary School Guestling-Bradshaw CE Primary School Hailsham Community College Academy Trust Hamsey Community Primary School Hankham Primary School Harbour Primary and Nursery School Harlands Primary School Hawkes Farm Primary School Hazel Court Sixth Form Hazel Court Special School Heathfield Community College Hellingly Community Primary School Heron Park Primary Academy Herstmonceux Primary School High Cliff Academy High Hurstwood CE Primary School Hollington Primary Academy Holy Cross CE Primary School Hurst Green CE Primary School Icklesham CE Primary School Iford and Kingston CE Primary School Jarvis Brook Primary School King Offa Primary Academy Kings Academy Langney Primary School Laughton Community Primary School Little Common School Little Horsted CE Primary School Manor Primary School Mark Cross Church of England Primary School Mayfield Church of Engalnd Primary School Maynards Green Community Primary School Meridian Primary School Motcombe Community School Netherfield CE Primary School New Horizons Academy Newick CE Primary School Ninfield Church of England Primary School Northiam CE Primary School Nutley CE Primary School Oakwood Primary Academy Ocklynge Junior School Ore Village Primary Academy Park Mead Primary School Parkland Infant School Parkland Junior School Parkside Community Primary School Pashley Down Infant School Peacehaven Community School Peacehaven Heights Primary School Peasmarsh CE Primary School Pebsham Primary Academy Pevensey and Westham CE Primary School Phoenix Academy Plumpton College Plumpton Primary School Polegate Primary School Priory School Punnetts Town Community Primary School Ratton School Ringmer Primary School Ringmer Sixth Form Robertsbridge Community College Robsack Wood Primary Academy Rocks Park Primary School Roselands Infants' School Rotherfield Primary School Rye College Rye Primary Sacred Heart Catholic Primary School, Hastings Salehurst Church Of England Primary School Sandown Primary School Saxon Mount School Seaford Head School Seaford Primary School Seaford Sixth Form Seahaven Academy Sedlescombe CE Primary School Shinewater Primary School Silverdale Primary Academy Sir Henry Fermor CE Primary School South Malling CE Primary School Southover CE Primary School St Andrew's CE Infants School St Catherine's College St John's CE Primary School St John's Meads CE Primary School St Leonards CE Primary School St Mark's CE Primary School St Mary Magdalene's Catholic Primary School St Mary Star of the Sea Catholic Primary School St Mary the Virgin CE Primary School St Marys Catholic Primary School St Mary's Horam St Michael's CE Primary School St Michael's Primary School St Pancras Catholic Primary School St Paul's CE Primary School St Peter and St Paul Church of Engalnd Primary School St Phillip's Catholic Primary School St Thomas A Becket Catholic Infant School St Thomas A Becket Catholic Junior School St Thomas' Chuch of England Primary School St. Richards Catholic College Stafford Junior School Staplecross Methodist Primary School Stone Cross School Stonegate CE Primary School Telscombe Cliffs Community Primary School The Baird Primary Academy The Causeway School The Eastbourne Academy The Hastings Academy The Haven Voluntary Aided CofE/Methodist Primary School The Lindfield School The South Downs School The St Leonards Academy Ticehurst and Flimwell Tollgate Community Junior School Torfield School Uckfield Community Technical College, Sixth Form Uplands Community College UTC @ Harbourside Wadhurst Church of England Primary School Wallands Community Primary School West Rise Infants West Rise Junior School West St Leonards Primary Academy Western Road Community Primary School Westfield Primary School White House Academy Willingdon Community School Willingdon Primary School Wivelsfield Primary School Other
If other school, please specify
Year group
If applicable and for year 8 and above please ensure that you have the child’s consent to refer.
Child/young person GP name*
Child/young person GP address*
GP phone number*
Parent/carer details Parent/carer name*
Is their address the same as the child/young person?* Parent/carer address*
Parent/carer’s phone number*
Does parent/carer consent to receiving text reminders for appointments as appropriate? Any additional information
Reason for referral Reason for referral* Please select... Bowel and bladder 4-11 (primary aged children who have trouble with wetting and bowel issues) Healthy You 4-11 (primary aged children who have multiple difficulties i.e. sleep, diet, physical activity, gadgets and screen time, puberty, hygiene and growing up) Healthy Sleep 4-11 (primary aged children who have trouble settling at night or staying a sleep throughout the night) Emotional health and wellbeing 4-11 (primary aged children who need support with worries, feelings, friendships, coping mechanisms, self-care or self-esteem / confidence Ready Steady Go (an 8 week Tier 2 weight management programme primarily designed for children aged 4-11 years who have a BMI equal to or over the 91st centile) Healthy You 11-19 - please use the young person referral form Health care plan for long term conditions (support to schools with completing or reviewing a HCP) Hearing test (children and young people where there are concerns about their hearing) None of the above
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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* What is happening with the child or young person that concerns you?
Strengths* What supportive measures have been tried or are in place?
Desired outcome of the referral*
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?* Please detail caring responsibilities*
Is the child/young person a looked after child? Is an Education Health Care Plan in place?* Please give details*
Are other agencies involved?* Please specify which agency and why they are involved?*
Are there any safeguarding concerns?* Please specify safeguarding concerns*
Have you sought advice regarding these concerns?* From who and what actions have you taken?*
Why haven't you sought advice?*
Has this been referred to social services?* Date referred* Outcome of referral*
Has a referral been made to Early Help?* Date completed* Has the child/young person/family been assessed by Early Help?* What were the interventions and outcomes?*
Referrer details Name of referrer*
Referrers role* Please select... Early Help School Staff Porchlight GP Early Help Practitioner GP KCHFT School Health Social Worker Other
Other role*
Designation*
Date of referral*
DD slash MM slash YYYY
Address*
Phone number*
Email*
Information sharing agreement The parent / carer / young person has been informed of the following:
Records are kept securely and confidentiality is respected in accordance with the Data Protection Act 2018 and the General Data Protection Regulation. We have a duty to refer to Social Services any child or adult who may be in need of protection.
Information will be shared and discussed between professionals and other agencies to help you/your child and family. You will be consulted following these discussions regarding any future planning and actions.
You understand that you have the right to object to my information being processed by Kent Community Health NHS Foundation Trust, but that this may result in the Trust not being able to treat you/your child or your family.
Signature* Date*
DD slash MM slash YYYY
Attachment(s) If you have any additional information please add any related documents here.
Request for attendance at transition event Name of school* Home educated Not in education, training or employment Alfriston School All Saints And St Richards CE Primary School All Saints CE Junior Academy (Hastings) All Saints CE Primary School (Bexhill) Annecy Primary School Ark Blacklands Primary Academy Ark Castledown Primary School ARK Helenswood Academy Ark Little Ridge Primary Academy Ark Sixth Form ARK William Parker Academy Ashdown Primary Barcombe CE Primary School Battle and Langton CE Primary School Beacon Community College Academy Trust Beckley CE Primary School Bexhill Academy Bexhill Sixth Form College Blackboys CE Primary School Bodiam CE Primary School Bonners CE Primary School Bourne Primary School Breakwater Academy Brede Primary School Broad Oak Community Primary School Burfield Academy Burwash Church of England Prinmary School Buxted CE Primary School Catsfield Church of England Primary School Cavendish School Academy Trust Chailey School Chailey St Peter's CE Primary School Chantry Community Primary School Chiddingly Primary School Christ Church CE Primary School Churchwood Primary Academy Chyngton School Claverham Community College Cradle Hill Cross-in-Hand Church of England Primary School Crowhurst CE Primary School Cuckmere House, School, Seaford Dallington CE Primary School Danehill CE Primary School Denton Community Primary School and Nursery Ditchling (St Margaret's) CE Primary School Dudley Infant Academy East Sussex College Eastbourne East Sussex College Hastings East Sussex College Lewes East Hoathly CE Primary School Etchingham CE Primary School Firle CE Primary School Five Ashes Church of England Primary School Fletching CE Primary School Forest Row CE Primary School Framfield CE Primary School Frant Church of England Primary School Gildredge House Glenleigh Park Primary Academy Glyne Gap Academy Groombridge St Thomas' CE Primary School Grove Park Primary Grove Park Secondary Grovelands Community Primary School Guestling-Bradshaw CE Primary School Hailsham Community College Academy Trust Hamsey Community Primary School Hankham Primary School Harbour Primary and Nursery School Harlands Primary School Hawkes Farm Primary School Hazel Court Sixth Form Hazel Court Special School Heathfield Community College Hellingly Community Primary School Heron Park Primary Academy Herstmonceux Primary School High Cliff Academy High Hurstwood CE Primary School Hollington Primary Academy Holy Cross CE Primary School Hurst Green CE Primary School Icklesham CE Primary School Iford and Kingston CE Primary School Jarvis Brook Primary School King Offa Primary Academy Kings Academy Langney Primary School Laughton Community Primary School Little Common School Little Horsted CE Primary School Manor Primary School Mark Cross Church of England Primary School Mayfield Church of Engalnd Primary School Maynards Green Community Primary School Meridian Primary School Motcombe Community School Netherfield CE Primary School New Horizons Academy Newick CE Primary School Ninfield Church of England Primary School Northiam CE Primary School Nutley CE Primary School Oakwood Primary Academy Ocklynge Junior School Ore Village Primary Academy Park Mead Primary School Parkland Infant School Parkland Junior School Parkside Community Primary School Pashley Down Infant School Peacehaven Community School Peacehaven Heights Primary School Peasmarsh CE Primary School Pebsham Primary Academy Pevensey and Westham CE Primary School Phoenix Academy Plumpton College Plumpton Primary School Polegate Primary School Priory School Punnetts Town Community Primary School Ratton School Ringmer Primary School Ringmer Sixth Form Robertsbridge Community College Robsack Wood Primary Academy Rocks Park Primary School Roselands Infants' School Rotherfield Primary School Rye College Rye Primary Sacred Heart Catholic Primary School, Hastings Salehurst Church Of England Primary School Sandown Primary School Saxon Mount School Seaford Head School Seaford Primary School Seaford Sixth Form Seahaven Academy Sedlescombe CE Primary School Shinewater Primary School Silverdale Primary Academy Sir Henry Fermor CE Primary School South Malling CE Primary School Southover CE Primary School St Andrew's CE Infants School St Catherine's College St John's CE Primary School St John's Meads CE Primary School St Leonards CE Primary School St Mark's CE Primary School St Mary Magdalene's Catholic Primary School St Mary Star of the Sea Catholic Primary School St Mary the Virgin CE Primary School St Marys Catholic Primary School St Mary's Horam St Michael's CE Primary School St Michael's Primary School St Pancras Catholic Primary School St Paul's CE Primary School St Peter and St Paul Church of Engalnd Primary School St Phillip's Catholic Primary School St Thomas A Becket Catholic Infant School St Thomas A Becket Catholic Junior School St Thomas' Chuch of England Primary School St. Richards Catholic College Stafford Junior School Staplecross Methodist Primary School Stone Cross School Stonegate CE Primary School Telscombe Cliffs Community Primary School The Baird Primary Academy The Causeway School The Eastbourne Academy The Hastings Academy The Haven Voluntary Aided CofE/Methodist Primary School The Lindfield School The South Downs The St Leonards Academy Ticehurst and Flimwell Tollgate Community Junior School Torfield School Uckfield Community Technical College, Sixth Form Uplands Community College UTC @ Harbourside Wadhurst Church of England Primary School Wallands Community Primary School West Rise Infants West Rise Junior School West St Leonards Primary Academy Western Road Community Primary School Westfield Primary School White House Academy Willingdon Community School Willingdon Primary School Wivelsfield Primary School
Name*
Designation*
Phone*
Email*
Date of transition event*
DD slash MM slash YYYY
Time of transition event* Request for Primary School health promotion event Name of school* Home educated Not in education, training or employment Alfriston School All Saints And St Richards CE Primary School All Saints CE Junior Academy (Hastings) All Saints CE Primary School (Bexhill) Annecy Primary School Ark Blacklands Primary Academy Ark Castledown Primary School ARK Helenswood Academy Ark Little Ridge Primary Academy Ark Sixth Form ARK William Parker Academy Ashdown Primary Barcombe CE Primary School Battle and Langton CE Primary School Beacon Community College Academy Trust Beckley CE Primary School Bexhill Academy Bexhill Sixth Form College Blackboys CE Primary School Bodiam CE Primary School Bonners CE Primary School Bourne Primary School Breakwater Academy Brede Primary School Broad Oak Community Primary School Burfield Academy Burwash Church of England Prinmary School Buxted CE Primary School Catsfield Church of England Primary School Cavendish School Academy Trust Chailey School Chailey St Peter's CE Primary School Chantry Community Primary School Chiddingly Primary School Christ Church CE Primary School Churchwood Primary Academy Chyngton School Claverham Community College Cradle Hill Cross-in-Hand Church of England Primary School Crowhurst CE Primary School Cuckmere House, School, Seaford Dallington CE Primary School Danehill CE Primary School Denton Community Primary School and Nursery Ditchling (St Margaret's) CE Primary School Dudley Infant Academy East Sussex College Eastbourne East Sussex College Hastings East Sussex College Lewes East Hoathly CE Primary School Etchingham CE Primary School Firle CE Primary School Five Ashes Church of England Primary School Fletching CE Primary School Forest Row CE Primary School Framfield CE Primary School Frant Church of England Primary School Gildredge House Glenleigh Park Primary Academy Glyne Gap Academy Groombridge St Thomas' CE Primary School Grove Park Primary Grove Park Secondary Grovelands Community Primary School Guestling-Bradshaw CE Primary School Hailsham Community College Academy Trust Hamsey Community Primary School Hankham Primary School Harbour Primary and Nursery School Harlands Primary School Hawkes Farm Primary School Hazel Court Sixth Form Hazel Court Special School Heathfield Community College Hellingly Community Primary School Heron Park Primary Academy Herstmonceux Primary School High Cliff Academy High Hurstwood CE Primary School Hollington Primary Academy Holy Cross CE Primary School Hurst Green CE Primary School Icklesham CE Primary School Iford and Kingston CE Primary School Jarvis Brook Primary School King Offa Primary Academy Kings Academy Langney Primary School Laughton Community Primary School Little Common School Little Horsted CE Primary School Manor Primary School Mark Cross Church of England Primary School Mayfield Church of Engalnd Primary School Maynards Green Community Primary School Meridian Primary School Motcombe Community School Netherfield CE Primary School New Horizons Academy Newick CE Primary School Ninfield Church of England Primary School Northiam CE Primary School Nutley CE Primary School Oakwood Primary Academy Ocklynge Junior School Ore Village Primary Academy Park Mead Primary School Parkland Infant School Parkland Junior School Parkside Community Primary School Pashley Down Infant School Peacehaven Community School Peacehaven Heights Primary School Peasmarsh CE Primary School Pebsham Primary Academy Pevensey and Westham CE Primary School Phoenix Academy Plumpton College Plumpton Primary School Polegate Primary School Priory School Punnetts Town Community Primary School Ratton School Ringmer Primary School Ringmer Sixth Form Robertsbridge Community College Robsack Wood Primary Academy Rocks Park Primary School Roselands Infants' School Rotherfield Primary School Rye College Rye Primary Sacred Heart Catholic Primary School, Hastings Salehurst Church Of England Primary School Sandown Primary School Saxon Mount School Seaford Head School Seaford Primary School Seaford Sixth Form Seahaven Academy Sedlescombe CE Primary School Shinewater Primary School Silverdale Primary Academy Sir Henry Fermor CE Primary School South Malling CE Primary School Southover CE Primary School St Andrew's CE Infants School St Catherine's College St John's CE Primary School St John's Meads CE Primary School St Leonards CE Primary School St Mark's CE Primary School St Mary Magdalene's Catholic Primary School St Mary Star of the Sea Catholic Primary School St Mary the Virgin CE Primary School St Marys Catholic Primary School St Mary's Horam St Michael's CE Primary School St Michael's Primary School St Pancras Catholic Primary School St Paul's CE Primary School St Peter and St Paul Church of Engalnd Primary School St Phillip's Catholic Primary School St Thomas A Becket Catholic Infant School St Thomas A Becket Catholic Junior School St Thomas' Chuch of England Primary School St. Richards Catholic College Stafford Junior School Staplecross Methodist Primary School Stone Cross School Stonegate CE Primary School Telscombe Cliffs Community Primary School The Baird Primary Academy The Causeway School The Eastbourne Academy The Hastings Academy The Haven Voluntary Aided CofE/Methodist Primary School The Lindfield School The South Downs The St Leonards Academy Ticehurst and Flimwell Tollgate Community Junior School Torfield School Uckfield Community Technical College, Sixth Form Uplands Community College UTC @ Harbourside Wadhurst Church of England Primary School Wallands Community Primary School West Rise Infants West Rise Junior School West St Leonards Primary Academy Western Road Community Primary School Westfield Primary School White House Academy Willingdon Community School Willingdon Primary School Wivelsfield Primary School
Name*
Designation*
Phone*
Email*
Health promotion event topic* Please select... Sleep Puberty year 5 and 6 only Oral health Healthy Eating Sun Safety
Please evidence from your school health profile how this health promotion event will support your school health action plan*
Please evidence how this health promotion event will fit with your planned RSHE programme and published policy*
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.
Year group*
If applicable and for year 8 and above please ensure that you have the child’s consent to refer.
Number of pupils*
Term for delivery*
Health Visiting transition Name*
Date of birth* Gender*
Ethnicity* Please select... White British White Irish Any other white background White and black Caribbean White and black African White and Asian Any other mixed background Indian Pakistani Bangladeshi Chinese Any other Asian background African Caribbean Any other black background Any other ethnic group Patient declined Not stated
Other, please specify*
Address*
Phone*
Parental email address*
School* Please select... Home educated Not in education, training or employment Alfriston School All Saints And St Richards CE Primary School All Saints CE Junior Academy (Hastings) All Saints CE Primary School (Bexhill) Annecy Primary School Ark Blacklands Primary Academy Ark Castledown Primary School ARK Helenswood Academy Ark Little Ridge Primary Academy Ark Sixth Form ARK William Parker Academy Ashdown Primary Barcombe CE Primary School Battle and Langton CE Primary School Beacon Community College Academy Trust Beckley CE Primary School Bexhill Academy Bexhill Sixth Form College Blackboys CE Primary School Bodiam CE Primary School Bonners CE Primary School Bourne Primary School Breakwater Academy Brede Primary School Broad Oak Community Primary School Burfield Academy Burwash Church of England Prinmary School Buxted CE Primary School Catsfield Church of England Primary School Cavendish School Academy Trust Chailey School Chailey St Peter's CE Primary School Chantry Community Primary School Chiddingly Primary School Christ Church CE Primary School Churchwood Primary Academy Chyngton School Claverham Community College Cradle Hill Cross-in-Hand Church of England Primary School Crowhurst CE Primary School Cuckmere House, School, Seaford Dallington CE Primary School Danehill CE Primary School Denton Community Primary School and Nursery Ditchling (St Margaret's) CE Primary School Dudley Infant Academy East Sussex College Eastbourne East Sussex College Hastings East Sussex College Lewes East Hoathly CE Primary School Etchingham CE Primary School Firle CE Primary School Five Ashes Church of England Primary School Fletching CE Primary School Forest Row CE Primary School Framfield CE Primary School Frant Church of England Primary School Gildredge House Glenleigh Park Primary Academy Glyne Gap Academy Groombridge St Thomas' CE Primary School Grove Park Primary Grove Park Secondary Grovelands Community Primary School Guestling-Bradshaw CE Primary School Hailsham Community College Academy Trust Hamsey Community Primary School Hankham Primary School Harbour Primary and Nursery School Harlands Primary School Hawkes Farm Primary School Hazel Court Sixth Form Hazel Court Special School Heathfield Community College Hellingly Community Primary School Heron Park Primary Academy Herstmonceux Primary School High Cliff Academy High Hurstwood CE Primary School Hollington Primary Academy Holy Cross CE Primary School Hurst Green CE Primary School Icklesham CE Primary School Iford and Kingston CE Primary School Jarvis Brook Primary School King Offa Primary Academy Kings Academy Langney Primary School Laughton Community Primary School Little Common School Little Horsted CE Primary School Manor Primary School Mark Cross Church of England Primary School Mayfield Church of Engalnd Primary School Maynards Green Community Primary School Meridian Primary School Motcombe Community School Netherfield CE Primary School New Horizons Academy Newick CE Primary School Ninfield Church of England Primary School Northiam CE Primary School Nutley CE Primary School Oakwood Primary Academy Ocklynge Junior School Ore Village Primary Academy Park Mead Primary School Parkland Infant School Parkland Junior School Parkside Community Primary School Pashley Down Infant School Peacehaven Community School Peacehaven Heights Primary School Peasmarsh CE Primary School Pebsham Primary Academy Pevensey and Westham CE Primary School Phoenix Academy Plumpton College Plumpton Primary School Polegate Primary School Priory School Punnetts Town Community Primary School Ratton School Ringmer Primary School Ringmer Sixth Form Robertsbridge Community College Robsack Wood Primary Academy Rocks Park Primary School Roselands Infants' School Rotherfield Primary School Rye College Rye Primary Sacred Heart Catholic Primary School, Hastings Salehurst Church Of England Primary School Sandown Primary School Saxon Mount School Seaford Head School Seaford Primary School Seaford Sixth Form Seahaven Academy Sedlescombe CE Primary School Shinewater Primary School Silverdale Primary Academy Sir Henry Fermor CE Primary School South Malling CE Primary School Southover CE Primary School St Andrew's CE Infants School St Catherine's College St John's CE Primary School St John's Meads CE Primary School St Leonards CE Primary School St Mark's CE Primary School St Mary Magdalene's Catholic Primary School St Mary Star of the Sea Catholic Primary School St Mary the Virgin CE Primary School St Marys Catholic Primary School St Mary's Horam St Michael's CE Primary School St Michael's Primary School St Pancras Catholic Primary School St Paul's CE Primary School St Peter and St Paul Church of Engalnd Primary School St Phillip's Catholic Primary School St Thomas A Becket Catholic Infant School St Thomas A Becket Catholic Junior School St Thomas' Chuch of England Primary School St. Richards Catholic College Stafford Junior School Staplecross Methodist Primary School Stone Cross School Stonegate CE Primary School Telscombe Cliffs Community Primary School The Baird Primary Academy The Causeway School The Eastbourne Academy The Hastings Academy The Haven Voluntary Aided CofE/Methodist Primary School The Lindfield School The South Downs School The St Leonards Academy Ticehurst and Flimwell Tollgate Community Junior School Torfield School Uckfield Community Technical College, Sixth Form Uplands Community College UTC @ Harbourside Wadhurst Church of England Primary School Wallands Community Primary School West Rise Infants West Rise Junior School West St Leonards Primary Academy Western Road Community Primary School Westfield Primary School White House Academy Willingdon Community School Willingdon Primary School Wivelsfield Primary School Other
GP*
Family 1st language
Name of parent/carer(s)
A referral can not be made without parent/carer (s) knowledge. Please confirm how the parent/carer(s) was informed* Referrer name*
Referrer phone*
Referrer email*
Criteria for handover Please tick all boxes that apply.
If you have had a conversation with a member of the ESSH about this referral please state who
Summary of health visiting intervention
Details of other agencies involved including names and contact details.* For example, social services. Including named practitioner and their email address and phone number. Please write none if no agency involvement.
Children on Child Protection Plan need to have copies of the following documents attached to the referral Initial case conference report and minutes.
Most recent Health Visiting Case Conference report. Any referrals made by Health visiting service and outcomes including SORs.
Young person referral You will need to show the legal basis for referring this parent/carer/young person (We will not process your referral unless you indicate which applies below).
Article 6 (1) of the General Data Protection Regulation:* Referring agency details Referring agency*
Name and position of referrer*
Phone*
Email*
Young person details Name*
Date of birth* Ethnicity* Please select... White - British White - Irish White - Other Mixed - White and Black Caribbean Mixed - White and Black African Any other mixed* Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Any other Asian background* Black or Black British - Caribbean Black or Black British - African Any other Black background* Chinese or other Ethnic - Chinese Chinese or other Ethnic - Vietnamese Any other Ethnic group* Traveller community Decline to provide
Contact address*
Phone*
Email*
How would the young person like us to contact them?* School* Type to search for school... Home educated Not in education, training or employment Alfriston School All Saints And St Richards CE Primary School All Saints CE Junior Academy (Hastings) All Saints CE Primary School (Bexhill) Annecy Primary School Ark Blacklands Primary Academy Ark Castledown Primary School ARK Helenswood Academy Ark Little Ridge Primary Academy Ark Sixth Form ARK William Parker Academy Ashdown Primary Barcombe CE Primary School Battle and Langton CE Primary School Beacon Community College Academy Trust Beckley CE Primary School Bexhill Academy Bexhill Sixth Form College Blackboys CE Primary School Bodiam CE Primary School Bonners CE Primary School Bourne Primary School Breakwater Academy Brede Primary School Broad Oak Community Primary School Burfield Academy Burwash Church of England Prinmary School Buxted CE Primary School Catsfield Church of England Primary School Cavendish School Academy Trust Chailey School Chailey St Peter's CE Primary School Chantry Community Primary School Chiddingly Primary School Christ Church CE Primary School Churchwood Primary Academy Chyngton School Claverham Community College Cradle Hill Cross-in-Hand Church of England Primary School Crowhurst CE Primary School Cuckmere House, School, Seaford Dallington CE Primary School Danehill CE Primary School Denton Community Primary School and Nursery Ditchling (St Margaret's) CE Primary School Dudley Infant Academy East Sussex College Eastbourne East Sussex College Hastings East Sussex College Lewes East Hoathly CE Primary School Etchingham CE Primary School Firle CE Primary School Five Ashes Church of England Primary School Fletching CE Primary School Forest Row CE Primary School Framfield CE Primary School Frant Church of England Primary School Gildredge House Glenleigh Park Primary Academy Glyne Gap Academy Groombridge St Thomas' CE Primary School Grove Park Primary Grove Park Secondary Grovelands Community Primary School Guestling-Bradshaw CE Primary School Hailsham Community College Academy Trust Hamsey Community Primary School Hankham Primary School Harbour Primary and Nursery School Harlands Primary School Hawkes Farm Primary School Hazel Court Sixth Form Hazel Court Special School Heathfield Community College Hellingly Community Primary School Heron Park Primary Academy Herstmonceux Primary School High Cliff Academy High Hurstwood CE Primary School Hollington Primary Academy Holy Cross CE Primary School Hurst Green CE Primary School Icklesham CE Primary School Iford and Kingston CE Primary School Jarvis Brook Primary School King Offa Primary Academy Kings Academy Langney Primary School Laughton Community Primary School Little Common School Little Horsted CE Primary School Manor Primary School Mark Cross Church of England Primary School Mayfield Church of Engalnd Primary School Maynards Green Community Primary School Meridian Primary School Motcombe Community School Netherfield CE Primary School New Horizons Academy Newick CE Primary School Ninfield Church of England Primary School Northiam CE Primary School Nutley CE Primary School Oakwood Primary Academy Ocklynge Junior School Ore Village Primary Academy Park Mead Primary School Parkland Infant School Parkland Junior School Parkside Community Primary School Pashley Down Infant School Peacehaven Community School Peacehaven Heights Primary School Peasmarsh CE Primary School Pebsham Primary Academy Pevensey and Westham CE Primary School Phoenix Academy Plumpton College Plumpton Primary School Polegate Primary School Priory School Punnetts Town Community Primary School Ratton School Ringmer Primary School Ringmer Sixth Form Robertsbridge Community College Robsack Wood Primary Academy Rocks Park Primary School Roselands Infants' School Rotherfield Primary School Rye College Rye Primary Sacred Heart Catholic Primary School, Hastings Salehurst Church Of England Primary School Sandown Primary School Saxon Mount School Seaford Head School Seaford Primary School Seaford Sixth Form Seahaven Academy Sedlescombe CE Primary School Shinewater Primary School Silverdale Primary Academy Sir Henry Fermor CE Primary School South Malling CE Primary School Southover CE Primary School St Andrew's CE Infants School St Catherine's College St John's CE Primary School St John's Meads CE Primary School St Leonards CE Primary School St Mark's CE Primary School St Mary Magdalene's Catholic Primary School St Mary Star of the Sea Catholic Primary School St Mary the Virgin CE Primary School St Marys Catholic Primary School St Mary's Horam St Michael's CE Primary School St Michael's Primary School St Pancras Catholic Primary School St Paul's CE Primary School St Peter and St Paul Church of Engalnd Primary School St Phillip's Catholic Primary School St Thomas A Becket Catholic Infant School St Thomas A Becket Catholic Junior School St Thomas' Chuch of England Primary School St. Richards Catholic College Stafford Junior School Staplecross Methodist Primary School Stone Cross School Stonegate CE Primary School Telscombe Cliffs Community Primary School The Baird Primary Academy The Causeway School The Eastbourne Academy The Hastings Academy The Haven Voluntary Aided CofE/Methodist Primary School The Lindfield School The South Downs School The St Leonards Academy Ticehurst and Flimwell Tollgate Community Junior School Torfield School Uckfield Community Technical College, Sixth Form Uplands Community College UTC @ Harbourside Wadhurst Church of England Primary School Wallands Community Primary School West Rise Infants West Rise Junior School West St Leonards Primary Academy Western Road Community Primary School Westfield Primary School White House Academy Willingdon Community School Willingdon Primary School Wivelsfield Primary School Other
GP name*
GP address*
Hidden
OLD INACTIVE Are social care involved? Hidden
OLD INACTIVE Multi-agency involvement? Organsation and practitioner.
Contact details
Referral reason Reason for referral* Please select... Targeted emotional health and wellbeing (Year 7 to Year 11 who have mild to moderate mental health difficulties) Healthy You 11-19 (young people aged 11-19 to improve health and lifestyles i.e. relationships, sexual health, puberty, emotional health, substance misuse, smoking, sleep, eating, weight, exercise - enabling them to identify their own goals) Health Care Plan (support to schools with completing or reviewing a HCP)
Criteria – schools eligible for targeted EHWB (Year 7 to Year 11)* You have to select an eligible school to continue.
Please select... Rye College Uplands Community College Heathfield Community College Uckfield College St Catherine’s College Eastbourne Academy Willingdon Community College Beacon Academy Kings Academy Priory School Chailey Secondary St Leonards Academy (Year 10 and Year11 Only) Hastings Academy (Year 10 and Year11 Only) ARK Alexandra
Concerns*
Strengths*
Desired outcome of the referral*
Questions about the young person Is this child/young person a young carer?* Please detail caring responsibilities*
Is the child/young person a looked after child?* Is an Education Health Care Plan in place?* Please give details*
Are other agencies involved?* Please specify which agency and why they are involved?*
Are there any safeguarding concerns?* Please specify safeguarding concerns*
Have you sought advice regarding these concerns?* Has a referral been made to Early Help?* Date completed*
DD slash MM slash YYYY
Has the child/young person/family been assessed by Early Help?* What were the interventions and outcomes?*
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?* If No – why has the young person not given consent?*
Parent/carers contact details*
Date*
MM slash DD slash YYYY
Hidden
Official use Hidden
Outcome of triage