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School Nurse Service Referral Form

Postal: CYP Admin Hub, School Nursing, Haleacre Unit, Amersham Hospital, Whielden Street, Amersham, Bucks. HP7 0JD

Please contact the school nursing team by phone: 01296 567833 or by email:

For more details of the revised School Nursing Service during the Covid-19 Pandemic please see:

Please complete all fields marked with an astrix (*)

School Nurse Service Referral Form

Interpreter required?:

Are there any safeguarding concerns?:

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

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

Other family members in household:

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

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

Does the child have any Special Educational needs?:

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):

Has the child self-consented if over 13? :

Is the child aware of your referral concerns?:

Does the child have an Educational Health Care Plan? :

Current Services already provided to family e.g.; health, education, social care, voluntary, “MHST Trailblazer”:

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

Thank you for your enquiry, we will be in touch shortly.