"*" indicates required fields NameThis field is for validation purposes and should be left unchanged.Child's/Young Person's Personal DetailsFirst Name * REQUIREDSurname * REQUIREDDate of Birth * REQUIREDDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NHS numberIf you do not know the child's NHS number, please follow this link to Find your NHS numberSex * REQUIRED---Please Select---FemaleMaleEthnicity * REQUIRED---Please Select---White – British (to include Northern Ireland, Scotland and Wales)White – IrishWhite – EuropeanWhite – OtherBlack or Black British – CaribbeanBlack or Black British – AfricanBlack – OtherAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – BangladeshiAsian – ChineseAsian – OtherMixed - White and Black CaribbeanMixed – White and Black AfricanMixed – White and AsianMixed – OtherEthnic identity not knownDo not wish to discloseMain language * REQUIREDAddress * REQUIRED Street Address Address Line 2 City / Town Post Code Is an interpreter needed? * REQUIRED---Please Select---NoYesContact DetailsFull name * REQUIREDRelationship to child * REQUIREDDoes this contact have parental responsibility? * REQUIRED Yes No Contact numberEmail address * REQUIRED Does parent need additional support, e.g completing forms? * REQUIRED---Please Select---YesNoProvide details of additional support requiredPreferred Contact Method * REQUIRED Phone Email Letter ConsentConsent obtained * REQUIRED---Please Select---ParentGuardianCarerYoung personYoung person - Gillick CompetentPlease note that referrals cannot be accepted without the consent of the child's parent/guardian/carer Additional InformationGPSchool---Please Select---PrimarySecondarySpecial Educational Needs SchoolElectively home educatedNot enrolled at schoolEnrolled but not attending school currentlySchool Name * REQUIREDGraduated Pathway (if applicable)---Please Select---My PlanMy Plan PlusStatement of SEN or EHCPSafeguarding---Please Select---NoYesEarly helpCurrent child in need planCurrent child protection planHistoric social care involvementCurrent ConcernPlease select area of current concern * REQUIRED Bereavement Bladder and bowel care Diet/Eating Issues Emotional/Mental Health Medical Issue Motor Skills Sexual Health Sleep Substance Misuse Other - please list Please select the current concern/s regarding bladder and bowel care? Night time wetting Day time wetting Constipation / soiling Toileting / toilet training Other Please describe in more detail you current concerns regarding bladder and bowel careHas the child / young person been seen by their GP for their bladder and bowel care? Yes No If yes, what was the advice given by GP?Is the child / young person currently taking any medication for their bladder and bowel care? Yes No If yes, what medication are they taking and how often?Please provide details of the current concern/s and also detail the current impact this is having on the child / young person * REQUIREDNo need to include details for bladder and bowel careProfessionals InvolvedHave any of the following professionals been involved? Advisory Teaching Service CYPS (previously known as CAMHS) Educational Psychologist GP Health Visiting Occupational Health Paediatrician Physiotherapist School Counsellor Social Worker Speech and Language Team Other - Please List If any professional involvement has been identified in box above please supply name and type of support in box belowReferrer DetailsFull name of referrer * REQUIREDRole of Referrer * REQUIREDContact Number * REQUIREDReferrer email * REQUIRED SummaryWhat do you hope to achieve through making this referral to the School Nursing Service? * REQUIREDWhat actions are you requesting of the School Nursing Service? * REQUIREDWhat interventions have been attempted or put in place to address the concern? * REQUIREDCAPTCHA