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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: bht.schoolhealth-enquiries@nhs.net

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

https://www.buckshealthcare.nhs.uk/coronavirus/cyp-service-changes.htm

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

Other family members in household:

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

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

Please include Name of services Contact names Tel numbers

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:

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

School Nurse Service Referral Form

School Nurse Service Referral Form

Safety measures remain in place in our Trust – Visitor restrictions still apply and everyone in our hospitals is required to wear a facemask, maintain social distancing and follow NHS safety measures.