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Community paediatric referral form: children under 5

Please refer to community paediatrics referral criteria document

All sections should be completed with as much detail as possible.
Referrals accepted only from education settings or healthcare professionals. Please be aware that if supporting evidence is not included, the referral will be returned.

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

This form will only be processed if completed electronically with the mandatory documents attached, and emailed to

To ensure the referral can be processed please include the following documents:

Please note: The referral form will download to your computer as a Word doc when you click on the ‘download document’ button.