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:

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 – suspended until further notice see GP 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 perceived threshold level based on BSCB Threshold Document 2015.

Referrer name:

Organisation:

Email:

Role:

Tel No:

Postcode:

Address: