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Community paediatric referral form: children under 5

Please download a copy of the form from this page, then complete all sections as required electronically before saving and emailing the completed document back to

If you do not have the relevant information, please discuss with the School SENDCO and parent/carer(s).

In this version of the form, the sections will expand to accommodate the text you enter

Please note that referrals acceptance must be met:

  • Children must be under a GP within the Buckinghamshire CCG boundaries
  • Under the age of 19 years, except:
    • Children who have recently moved into Buckinghamshire County/or Country
    • Attending a special school
    • Due to the potential need for Occupational Therapy of Speech and Language support we can only accept referrals for children who are registered with a Buckinghamshire GP

Please provide as much supporting information as possible including the below:

  • ASQ completed
  • Report from education setting
  • OT report or OT support from school setting for children with Dyspraxia/ Co-ordination problems
  • Portage report if under portage
  • Hearing assessment if completed
  • Speech and Language Therapies assessment for children with primary Social / Communication/Speech concerns
  • Reports confirming diagnosis & treatment to date if the child has been seen out of area previously or privately (For children already on medication, they should continue to receive private medication support, for children referred back to the NHS they will be seen in order of waiting times)

This form will only be accepted if completed electronically and emailed to