To refer email :
Child’s Name:
Address
Contact tel: / Child’s DOB:
School/ Nursery
Class/ Setting
Teacher’s/keyworkers Name: / Date:
Has an EHA been created / is one needed for support for the family ? / If yes
EHA ID number:
GP / Ethnicity
Is English another Language?
Is an interpreter required/
Medical History / diagnosis / Name of person completing the form:
Role:
Contact:
Has the family agreed to this information being shared in order to refer to appropriate services?
Please note if the child has needs for family support you must complete an EHA and inform us of the ID number- either include the below info in the EHA or complete this form and refer to it in the EHA.
In order to refer to the children’s Therapy services (SLT, OT, Phyiso) including those based at CDU which includes Portage –email this form to and state in the email which services you are expecting a response from i.e.
Children’s Speech and Language Therapy Occupational Therapy
Physiotherapy Equipment and Adaptations
Portage (pre school education support service)
Current Services/Agencies Involved:
Please supply any relevant / recent reports / PleaseTick
/Contact name if known:
Aiming High
ASD Partnership Project
Children’s Social Care
Clinical PsychologyCommunity Learning Disability Team
Dental
Dietitian
Educational Psychology
Equipment & Adaptations Service
Footsteps/Podiatry
Health Young Minds
Hearing
Looked After Children
Nurse Co-ordinator. Complex Medical Needs
Occupational Therapy
OrthopticPaediatrician
Physiotherapy
Portage
/ /School Nurse
Speech and Language/Feeding
Visually Impaired Service
DIRECTIONS
Please give as much detail as possible in the relevant areas and return the completed form securely following your organisation own information governance rules to the email address above. Once the completed form has been received, we will screen the information and the referrer and the family will receive an acknowledgment within 3 weeks and the child will be sent an appointment within 18 weeks. If for any reason you do not receive these please contact us as this may mean the referral has not been received.
What have you already tried?
Have you referred to the SEND guidance document? What have you already tried in order to support the child’s needs?
What are your main areas of concern? (Include if child is experiencing pain)
If the child is in early years please refer to the delays as identified by the EYFS age/stage bands or ages / stages Questionnaire 3 if your setting uses this tool – or submit these results with your referral (HV no need to do this as these are viewable on EMIS )
If the child is in school what level are they working to?
Please provide information on the child’s abilities and difficulties within the following areas and comment if you are aware if these issues also at home/school / nursery/outside school activities:
Listening and attention:
Following Instructions:
Expressing themselves (is it the content or the actual speech that is causing concern, i.e. swapping speech sounds, stammering, not speaking in certain situations, lack of vocab / sentence structure etc?)
Interaction with peers(turn taking, initiating interaction, eye contact)
If there are concerns around social communication disorders please complete the red flags tool.
Gross Motor Skills: (e.g. delays in sitting, crawling/ going up / down stairs, poor balance, ball skills, willingness to join in PE, avoidance of playground equipment etc.)
Fine Motor Skills: (e.g.hand grasps, immature pencil grip,reluctance with mark making, poor hand-eye coordination, scissor skills etc.)
Handwriting: (pencil control, letter formation, reversals, desk posture, pencil grip etc.)
Perception (difficulty organising self, sequencing, bumping into things)
Self-care Skills: (e.g. toileting, feeding, dressing, sleep etc.)
Feeding / Swallowing Difficulties (e.g. coughing during feeding, failure to thrive, difficulties chewing / swallowing)
Sensory: (e.g. touch sensitivity, movement sensitivity, sensory overload leading to poor attention, sensory seeking, e.g. can’t sit still, mouthing / biting objectslearns/looks with fingers, sensitivity to loud/sudden noises etc.)
If there are particular concerns around sensory issues please complete the red flags for sensory checklist
General Health (Attendance levels, health conditions, continence – soiling/ constipation/ enuresis)
Education: (attention, following instructions, finishing tasks, remembering information, reading/maths/spelling, sitting in circle time/snacktime/lunchtime etc.)
Behaviour: (difficulties with restlessness, coping with changes in routine, ability to interact with peers, avoidance, impulsivity, difficulty with temper etc.)
ANY ADDITIONAL INFORMATION/COMMENTS
Please attach your targeted intervention results e.g.
WELLCOMM or Language Link findings& resources used with their outcome/ impact to date and length of time these have been tried over.
Motor Skills United & resources used with their outcome/ impact to date and length of time these have been tried over.
Please list the interventions used from the SMBC Guidance for Early years Settings, Schools and SEN practitioners working with children & Young people with Special Educational Needs & Disabilities & the impact of these/ length of time tried over.
If you have any concerns about the child’s mental health/well-being, have you done a SDQ/Wemwebs checklist/ what does this tell you about the child’s well being?
/
Does the child have an EHC Plan?
Does the child have additional support at school/nursery/ in their setting? If ‘Yes’ please state how much:
Are any other agencies involved with the child? If ‘Yes’ please state which agencies and the type of involvement:
Is the child aware of their difficulties / any diagnoses(please list any diagnosis here with date and who diagnosed)
What are the Parents views / concerns about their child?
Are Parent / carers likely to attend appointments – school based, or at a clinic?
What are you hoping to achieve from this referral? E.g. training, further understanding of need etc.