Form Page | Gloucestershire Health and Care NHS Foundation Trust

Section 1: Patient details

Referrer/Practitioner’s Name and job title:(Required)

Patient's full name(Required)

First Last

Date of birth(Required)

NHS Number(Required)

Child's age(Required)

If less than 1, please state age in months or weeks.

Patients Ethnicity(Required)

If other, please tell us the patient's ethnicity

Address(Required)

Street Address Address Line 2 Postal code

Location(Required)

Phone number(Required)

If school age, name of patient's school and locality

Date of attendance(Required)

Time of attendance(Required)

Department attended(Required)

Is the patient accompanied?(Required)

Yes

Full name of person accompanying the patient(Required)

First Last

Relationship to patient of the accompanying person(Required)

CP-IS checked?(Required)

Yes

Have you informed a social worker?(Required)

Yes

Have you identified safeguarding concerns and completed a MARF? (It is the responsibility of the ED/PAU practitioner to complete a Multi-Agency Referral Form when concerns are raised)(Required)

Yes

Section 2: Mandatory referral

Refer 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)

Reason for referral

Injury category(Required)

If other, please describe the presenting complaint(Required)

If this is for a physical injury, how did this occur?

What actions have been taken?(Required)

What is the expectation from this referral?(Required)

Section 3: Parent/Carer concerns

This section is for parent / carers of pre-school aged children only – Refer Pre-school age children only to PLPHN. School Nursing DOES NOT accept referrals for parents/carers of school age children.

For 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. Please consider MARF if concerns identified.

Has a MARF been completed due to concerns about a parent/carer?(Required)

Yes

Please provide name, date of birth and address (if different) of pre-school children only

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