Has information sharing been discussed?(Required) Yes No Is the patient accompanied?(Required) Yes No Full name of person accompanying the patient(Required) First Last Relationship to child(Required) If school age, name of school and localityPhone number(Required)Patient's detailsFull name(Required) First Last Date of birth(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NHS Number(Required) Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code Date of attendance(Required) DD slash MM slash YYYY Time of attendance(Required) Hours : Minutes AM/PM AM PM AM/PM Department attended(Required)GRHCGHPAUMIIUReason for attendance/detail of presenting complaint. Provide clear information and offer context of the injury or complaint to enable the PLPHN to assess the need for further support: What is the expectation from this referral?(Required)CP-IS checked?(Required) Yes No You have answered no, please give a reason.(Required)Have you informed a social worker?(Required) Yes No Referral to Children’s Services identified?(Required) Yes No MARF completed?(Required) Yes No If any safeguarding concerns have been identified, it is the responsibility of the ED/MIIU/PAU practitioner to complete a Multi-Agency Referral Form (MARF). Mandatory referralRefer to the Paediatric Liaison Public Health Nurse (PLPHN) ALL children who meet the criteria below - more than one criteria may apply. The child is currently(Required) Subject to Child Protection Plan Child in Need Child in Care Suspected Child Exploitation (CE) None of these Child or young person’s attendance is due directly to(Required) Suspected non-accidental injury Concerns r.e: mechanism of injury Delayed presentation Self harm Mental ill health Substance misuse Alcohol misuse Suicidal thoughts Suicidal behaviour Assault Alleged bullying Teenage pregnancy Child/young person attending alone None of these - see reason for referral box Reason for referralPlease give details and reasons for your referral to PLPHN(Required)Parent/Carer concerns – Pre-school age children onlyFor example: Mental ill health, Substance Misuse Alcohol Misuse, Assault, Domestic Abuse, Aggression, Self-Harm, Parenting issues that may place a child at risk of harm. Please provide any supporting information within your reason for referral above.Has a MARF been completed due to concerns about a parent/carer who has pre-school children Yes No Please provide name, date of birth and address (if different) of pre-school children onlyReferrer/Practitioner’s Name and job title:(Required) CAPTCHA