Children’s Health Service Referral Form Form submitted to refer a child/young person to the Children’s Health Service "*" indicates required fields Important: This is not an emergency service If you are worried that a child or young person is in immediate danger or requires urgent medical or mental health support, please do not use this form. Crisis referrals If you believe the life of a child or young person is at immediate risk, please dial 999 straight away or go to the nearest Accident & Emergency department. This single referral form can be used for any of the seven teams within the Children’s Health Service, listed below. Health Visiting School Nursing Occupational Therapy Physiotherapy Speech and Language Therapy Young Minds Matter CAMHS – Child and Adolescent Mental Health Service We know that families and referrers often need support from more than one service. That’s why we’ve created a shared form—to reduce repetition and make it easier for you to provide the information we need. The details you give will help us understand the child or young person’s needs and make sure they are directed to the most appropriate service. To complete your referral, make sure you have: The name, date of birth and address for the child you are referring The name and contact details for the parent or carer and any other professionals involved Information about what support has been offered to the child and/or family. Important: We are unable to progress incomplete referrals, and these will be sent back with advice on next steps. Which service do you think best fits the child or young person’s needs? * REQUIRED Health Visiting School Nursing Occupational Therapy Physiotherapy Speech and Language Therapy Young Minds Matters CAMHS (Child and Adolescent Mental Health Service) Not Sure More information about CAMHS More information about Young Minds Matters More information about Childrens Physiotherapy More information about Childrens Occupational Therapy More information about Childrens Speech and Language Therapy More information about Health Visiting More information about School NursingInformation for Physiotherapy Referrals Only Physiotherapy do not routinely accept referrals for flat feet, in-toeing, out-toeing, bowed legs as these conditions are usually part of normal development and likely to improve without any intervention. Please see the leaflets below for more information. If you child is 16 and over and has a musculoskeletal condition they can be seen by the adult physiotherapy department If your childs problems is in relation to their foot/ankle, they can be seen by the podiatry department If your childs problem is related to their hands, please refer to hand therapy. We are a countywide Physiotherapy service covering Gloucestershire. This means you may be offered an appointment anywhere within Gloucestershire. Waiting for an appointment for your local centre may cause a delay in being seen. Physio Appointments will be offered in the clinic which is most suitable and as close to home as possible. If a sooner appointment is available this will be offered but might be at an alternative clinic. Please note that core opening hours for the Children and Young People's Physiotherapy Service are 8.30am to 4.30pm Monday to Friday I am making this referral for: * REQUIRED Myself (I am under 18 and live in Gloucestershire) My child (I am the parent/carer) A child/young person I support (I am a professional) Email of the person completing this form * REQUIRED Referrer DetailsReferrer full nameDate request made DD slash MM slash YYYY Referrer relationship to the child/young personReferrer contact telephoneReferrer alternative point of contactReferrer organisation (if applicable)ConsentHas the young person consented to this referral? * REQUIRED Yes No Does the young person have capacity to consent to this referral? Yes No Do not know Has the parent consented to this referral? * REQUIRED Yes No If you are making this request without parental agreement, provide an explanation why you are sharing the information without this.Information sharing consentSometimes we will need to share information with other agencies who might be able to help. We may also need to get additional information about the children and family from other agencies to help us to make the right decisions about the level of support that may be needed. These agencies may include: Education settings and educational support services (inc. Early Years) Other Health professionals in community or hospital settings Early Help Services Social Care Services Specialist support services (e.g. Talk Well, Young Gloucestershire, Domestic Abuse, Substance Misuse) Have the parents/carers and young person agreed that we can share this information with other agencies? * REQUIRED Yes No Please be aware that for parents/carers or young person not providing agreement to share information with other agencies this may limit what help and support we are able to recommend or provide.Please provide any information about any limits on this sharing information agreement e.g. parent requests for some but not all information to be shared which we will consider in making our decisions of what information sharing is proportionate and/or required to fulfil our public tasks.Contact information for arranging appointments and responding to referralWho is the preferred contact for responding to this referral and arranging appointments if required? * REQUIRED Directly with young person With parent / carer Best mobile phone for communications: * REQUIREDBest email address for communications: * REQUIRED Some appointments maybe able to be offered in school, please indicate preference below * REQUIRED OK to be seen in school Does not wish to be seen in school Your referral may be signposted to another agency, please indicate your preference for contact with another agency * REQUIRED Face to face Telephone call Online call Text chat Child/Young Person DetailsFull name * REQUIREDDate of birth * REQUIRED DD slash MM slash YYYY Address * REQUIRED Street Address Address Line 2 City or town Postal code Are they in education, training or employment ? * REQUIRED Yes No Name of education provider, training provider or employerAre they home schooled? Yes No Gender * REQUIRED Male Female Other Prefer not to say Preferred PronounsEthnicity / cultural identity * REQUIREDEnglish/Welsh/Scottish/Northern Irish/BritishIrishGypsy or Irish TravellerAny other White background, please describeWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed/Multiple ethnic background, please describeIndianPakistaniBangladeshiChineseAny other Asian background, please describeAfricanCaribbeanAny other Black/African/Caribbean background, please describeArabAny other ethnic group, please describePrefer not to discloseNot knownFirst language * REQUIREDIs an interpreter required? * REQUIRED Yes No Does the child or young person require any accessibility support to attend an assessment? Yes No Accessibility needsGP NameGP SurgeryFurther informationSchool attendance issues or exclusionsFor example, current school attendance percentage, are they on a part-time timetable due to mental health needs, are there any behaviour or exclusion issues at school? Does this child/young person receive any support in relation to a Special Educational Needs or Disability (SEND)? Disability Learning Psychological Sensory need Other None Is the child/young person on the Graduated Pathway Education Health Care Plan (EHCP) My Plan Plus My Plan Being explored Not on the Graduated Pathway Medical History (please include any relevant childhood illnesses, surgeries, allergies and interventions)Is the child/young person on any medication? * REQUIRED Yes No Please list the medication the young person or child is currently taking.Is the child/young person known to social care? CIC - Child in Care CP - Child Protection Plan CIN - Child in Need Plan Declined to disclose No Yes (currently) CIC/CP/CIN/Care Leaver Yes (previously) CIC/CP/CIN/Care Leaver Not known Is the child/young person a young carer? Declined to disclose Yes No Not known Does this request also involve a safeguarding concern? Yes - I have submitted a Multi‑Agency Referral Form (MARF) Yes - I have not submitted a Multi‑Agency Referral Form (MARF) No Parent / Carer DetailsParent / Carer Full name * REQUIREDDoes the parent or carer live at a different address from the child or young person? Yes No Parent / Carer contact address Street Address Address Line 2 City or town Postal Code Do they have parental responsibility? * REQUIRED Yes No Is an interpreter required for the parent? Yes No Parent first languageDoes the parent or carer require any accessibility support to attend an assessment? Yes No Accessibility needsDoes parent need additional support (e.g. completing forms)Are there any risks to staff when working with this family? No Yes – please detail Are there any risks to staff when working with this family - DetailsReason for ReferralWhy are you making this request? * REQUIREDWhat is the impact on the child/young person of the issues/concerns you've identified?How long has it been going on for? * REQUIRED(when was the difficulty first noticed) Less than 1 month 1 to 3 months 4 to 6 months 6 to 12 months Over 1 year Is the need: Getting worse Getting better Staying the same Any known self-harming behaviour in the last 3 months? None Mild Moderate Severe Not known Any known suicidal thought or acts? Yes - current Yes - historical No Not known What’s going well for the child/young person and family? What are the strengths?What are the views of the child/young person on this situation and this request?What are the parents' or carers' views on this situation and the referral?If at primary school please give the class teacher's email address. Is this referral for individual or group work? Individual Group If you have selected group, has this been discussed with a member of the YMM team? If so, who?Supporting the child/young person or familyWhat have you tried already to help * REQUIREDWhat are the views of the other professionals working with the child/young person about your concerns?Is there anything else we need to know to help us to make the right decisions for the child/young person?Incomplete referrals may not be acceptedPhysiotherapyWho is this Physiotherapy referral in relation to? Pre-school child School aged child / young person What is this referral in relation to * REQUIREDPlease tick all relevant issues. Rheumatology Neuromuscular condition Neurological condition Neck Back Elbow Wrist Shoulder Knee Hip Ankle / Foot Other Is this problem because of an injury or trauma? Yes No Not applicable If yes, please describe:Have you been experiencing any of the below symptoms. Please tick all that apply. Unexplained weight loss * REQUIRED Yes No Describe where the symptoms are, when they started, the frequency and severityPins and needles * REQUIRED Yes No Describe where the symptoms are, when they started, the frequency and severityNumbness * REQUIRED Yes No Describe where the symptoms are, when they started, the frequency and severityChanges in bladder or bowel function * REQUIRED Yes No Describe where the symptoms are, when they started, the frequency and severityNight pain * REQUIRED Yes No Describe where the symptoms are, when they started, the frequency and severityMorning stiffness lasting more than 30 minutes * REQUIRED Yes No Describe where the symptoms are, when they started, the frequency and severityConstant/ unrelenting pain * REQUIRED Yes No Describe where the symptoms are, when they started, the frequency and severityFunctional difficulties * REQUIRED Yes No Describe where the symptoms are, when they started, the frequency and severityPlease describe below if any of the following investigations have taken place:X-ray, MRI, ultrasound and / or blood testRegarding Birth History - Please provide as much detail as possible with regards to the birth history including prematurity, birth weight, any newborn concerns, admission to the neonatal unit.Regarding Development History - If appropriate, please provide details on your child’s development including when skills were achieved.Has the child displayed any loss in physical skills? Yes No Can the child accept weight through their legs in support, standing by 12 months old Yes No Has the child displayed signs of pain / discomfort when changing a nappy? Yes No Does the child use one side of their body more than the other? Yes No Occupational TherapyPlease tick the relevant box and provide details e.g. we need to know details of the difficulty i.e. is not able to focus attention on work set during classroom tasks without the support of an adult, is unable to tolerate having their teeth cleaned/washing their hands What are the child/young person functional difficulties?Daily Living Skills * REQUIRED Yes No Details of difficultyFunctional difficulties in the school environment * REQUIRED Yes No Details of difficultyAccess to home environment * REQUIRED Yes No Details of difficultyRelated to a planned surgery (please include date if known) * REQUIRED Yes No Details of difficultyOccupational Therapy referrals from education professionals for children with identified issues above which are related to coordination difficulties will need to show evidence of four terms of a movement programme. If there is no evidence, then the referral will be returned and can be re-submitted when the evidence is available. Has there been four terms of a movement programme? Yes No Evidence provided Yes No Speech and Language TherapyWhat type of Request is this? New request At least 6 months post last SLT contact Request for further episode of care for child already known to service
