NHS Children’s Care Coordination Team Referral

and/orKCC Portage Referral Form

This form can be used to refer children to the NHSChildren’s Care Coordination Team (formerly known as Early Support) where you feel a child would benefit from support from more than one health professional ( including keyworkers, speech and language therapy, occupational therapy, physiotherapy and community paediatrician).

The form can also be used to refer separatelyto Portage. If a referral is required to both the NHS Children’s Care Coordination Team and Portage please only complete the form once and send a copy to both services.

Child’s details
Child’s name / Date of Birth
NHS number/ Unique child no. / Gender
Type of referral (please tick)
Children’s Care Coordination Team / Kent Portage
Locality/Area (e.g. Canterbury, West Kent)
Details of the referrer
Name / Role
Agency/organisation
E-mail address / Phone number
Parent / carer details
Name / Phone number
Email address
First (or main) language used / Interpreter Required (Y/N)
Family address
House no / Town
Street / Postcode
Safeguarding
Is the child known to Social Services? / Yes/No
Is the child a Child in Need? / Yes/No
Is the child subject to a Child Protection Plan? / Yes/No
Is the child a Looked after child? / Yes/No
Local Authority with responsibility
Setting details (if attending)
Name and address of Pre-school setting
Contact name
Phone number / Number of hours child attends (per week)
Professionals currently involved
Profession / Name / Contact details
GP
Health Visitor
Key Worker
Consultant / Paediatrician
Occupational Therapist
Physiotherapist
Speech & Language Therapist
Social Care / Worker
Specialist Teaching & Learning Service
Specialist Teaching & Learning Service HI/VI/MSI
Early Help
Other
Main concerns and reasons for referral, please describe any diagnosis or difficulties including relevant birth and medical history (e.g. include any illnesses, medication, hospital admissions)
Please provide relevant developmental details (To include information about delayed early milestones, such as feeding, sitting, walking & talking)
Speech, language and communication (e.g. listening and attention, pointing, understanding; using words in sentences; speech sounds; getting on with other people)
Sensory - vision, hearing, touch
Eating, sleeping, personal care
Gross & Fine Motor Skills, e.g. sitting independently, walking, balance, running, handling objects
Socialisation & emotional development, e.g. play with or alongside other children, ability to relate to adults, eye contact, repetitive actions, attachment concerns
Medication
Please attach any relevant reports
Outcome sought from parent(s) / carer(s) from this referral
Parent / carer consent
The person signing this form needs to have Parental Responsibility* for the child/young person concerned. Only one signature is required.
  • *A mother automatically has parental responsibility for her child from birth.
  • In England and Wales, if the parents of a child are married to each other at the time of the birth, or if they have jointly adopted a child, then they share parental responsibility.
  • For couples who are not married: From 1 December 2003 a father shares parental responsibility if he jointly registers the birth of the child with the mother (ie he puts his name on the child’s birth certificate). Before 1 December 2003 a father must have signed a parental responsibility agreement with the mother or have obtained a parental responsibility order from court in order to share parental responsibility for the child.
  • Parents do not lose parental responsibility if they divorce. Parental responsibility can be changed by order of the Court.
By signing this form we / I consent to information being shared between the National Health Service (NHS), Kent County Council (KCC), and other agencies as appropriate in connection with the referral.
I agree to a referral being made by (name of referrer)………………………………………………………………………
on behalf of myself (name of parent / carer)……………………………………………………………………………………
and my child (name of child)……………………………………………………………………………………………………………
to the NHS Children’s Care Coordination Team and/or KCC Kent Portage
I understand that information may be shared between different professionals working with my family in connection with this referral, and that such professionals might include (amongst others), doctors, nurses, therapists, psychologists, social workers, portage workers, nursery staff and teachers.
Parent / Carer’s signature…………………………………...... Date……………………………….

For Children’s Care Coordination Team referrals please email the completed, signed referral form securely to the appropriate administrator for the area the child resides in (see below)

If you have concerns about sending information from an unsecure email address please contact the relevant team on the number below for the correct postal address.

Area / Contact Name/Service / Phone Number / Email Address
Dartford, Gravesham, Swanley / KCHFT Children’s Therapies Service / 01322 428242 /
Canterbury/Coastal / KCHFT Children’s Therapies Service / 01227 783042 /
Thanet / KCHFT Children’s Therapies Service / 03000 420871 /
Dover / EKHUFT Community Child Health / 01304 222521 /
Ashford / EKHUFT Community Child Health / 01233 651927 /
Shepway / EKHUFT Community Child Health / 01303 854461 /
Swale / Medway Community Healthcare / 03000 420943 /
West Kent – Maidstone & Malling / KCHFT Children’s Therapies Service / 01622 742333 /
West Kent – Tonbridge, Tunbridge Wells &Sevenoaks / KCHFT Children’s Therapies Service / 01892 501860 /

If you are only making a request for Portage support, please email the referral form securely to:

Or post by recorded delivery to:Kent Portage Service

The Dolphin Centre

Abbey Court

7 – 15 St Johns Road

Tunbridge Wells

Kent

TN4 9TF

If you are making a request for BOTH Children’s Care Coordination and Portage please send a copy of the referral to both teams, e.g. Portage AND NHS Children’s Care Coordination locality team.

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