Step 1 of 2 50% The patient I am referring is:(Required) a child an adult Has information sharing been discussed?(Required) Yes No Section 1: Patient detailsReferrer/Practitioner’s Name and job title:(Required)Patient's full name(Required) First Last Date of birth(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NHS Number(Required)Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code Phone number(Required)If school age, name of patient's school and localityDate of attendance(Required) DD slash MM slash YYYY Time of attendance(Required) Hours : Minutes AM/PM AM PM AM/PM Department attended(Required)GRHCGHPAUIs the patient accompanied?(Required) Yes No Full name of person accompanying the patient(Required) First Last Relationship to patient of the accompanying person(Required)CP-IS checked?(Required) Yes No Have you informed a social worker?(Required) Yes No 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 No Section 2: 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 referralReason for referral/Presenting complaint(Required)Reason for attendance/referral (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? Section 3: Parent/Carer concernsThis section is for parent/carers of pre-school aged children only – Refer re 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 is concerns identified.Has a MARF been completed due to concerns about a parent/carer? Yes No Please provide name, date of birth and address (if different) of pre-school children onlyCAPTCHA