School Nurse Service Referral Form

Child's full name*:

Gender*:

Date of Birth*:

Age*:

Address*:

Parent / carer's main language*:

Interpreter required?*:

Yes No

Are there any safeguarding concerns?*:

Yes No

Is the child above subject to a child protection plan? (Please forward CP Plan if referring from Social Care)*:

Yes No

School*:

Year group*:

Parents/carer name*:

Day time contact details*:

Preferred Email address*:

GP*:

NHS number (if known)*:

Child’s main spoken language*:

Ethnicity*:

Child’s mobile number: (optional)

Other significant family members not at the above address e.g. partner, parent, grandparent: (Parental Responsibility)*:

Yes No

Please include Relationship to child and School/Nursery if another child

Have parents/carers consented and are they aware of the details of this referral?* :

Yes No

Is the parent/carer aware that these details will be shared with school nursing?*:

Yes No

Does the child have any Special Educational needs?*:

Yes No

Has the parent/carer been on a parenting course? (NB. In most cases will we suggest the original referrer signposts the parents to a course before we will undertake a piece of work)*:

Yes No

Has the child self-consented if over 13?* :

Yes No

Is the child aware of your referral concerns?*:

Yes No

Does the child have an Educational Health Care Plan?* :

Yes No

Please give brief details

Please include Name of services Contact names Tel numbers*

Please Tick relevant box/boxes if there are concerns with any of the following: (Maximum two)

Resilience and emotional wellbeing Sleep and routines General advice for delayed toileting issues Healthy lifestyles Healthy relationships Attendance support with long term medical conditions Hearing assessment Individual Puberty advice and support Secondary school transition Parental separation / conflict Other give details

Other more details*

How long has this been affecting the child/young person?*

What areas of life is this problem impacting on for the child?*

What support is already in place?*

What have you done as a school/parent/carer to support the child in relation to the issue of this referral?*

What outcome is hoped for? What are the child/young person’s/parents’ goals?*

Any additional information: e.g. have you also completed a MARF and/or other referrals at the same time as this request? What is your threshold based on the Bucks Safeguarding Children Partnership Continuum of Need?*

Referrer name*:

Organisation*:

Email*:

Role*:

Tel No*:

Postcode*:

Address*: