Step 1 of 3 33% Tell us about the child Name of Child*Gender* Male Female Date of Birth*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NHS NumberAddress*Postcode*Tell us about this referralWhat are the parental/carer concerns?*What are the areas a WellChild nurse can help? Please select below what prompted you to refer to the WellChild nurse service* Financial support Respite Tertiary care service issues Transition to adult services Education concerns Difficulty with accessing services Accessing support networks Other Please provide any additional information which relates to the above ticked box?*What are the child’s concerns?*What is the desired outcome?*Tell us about the child's familyName*Relationship to childHome telephoneMobile telephone Tell us who provides care for this child ConsultantContact numberContact email GPContact numberContact email Social worker or lead professionalContact numberContact email Other Agencies involved in Care(Please provide contact details where available) Tell us about the child's diagnosis and the reason for this referral What is the medical diagnosis?Referral criteria 1Please selectProlonged inpatient care at level 3/4;Tertiary care managed by 2 or more specialist teams; Tertiary care managed by 1 specialist team but with health complicationsYP condition is complex to manage – organ transplant, complex multisystem condition, acquired brain injury, significantly life limitingReferral criteria 2Please selectNo clear overriding diagnosis for which accounts for all the medical conditions and/or ongoing conflict around the assessment or care plan for conditionRequires a central point of communication to guide and support a family through transition points e.g. From hospital to home or between servicesChild/YP not engaging with education and/or no discernible consistent understanding of YP educational needsSocial concerns such as housing, economic situation or parental capacity to manage conditionTell us about yourselfYour name*Your contact number*Your email* Tell us about consent for this referralHave parents or carers consented to this referral?* Yes No Do we have consent to share information?* Yes No CAPTCHA