WEST HERTS CHILDREN’S COMMUNITY EYE SERVICE

(A service for children and young people with known or suspected eye problems. These may include squint, reduced vision, refractive error, problems affecting eye movement or binocular vision, or double vision)

REFERRAL FORM

PLEASE COMPLETE THIS FORM IN FULL IN CONJUNCTION WITH THE REFERRAL CRITERIA. INCOMPLETE REFERRALS WILL BE RETURNED, RESULTING IN A DELAY TOTHE REFERRAL PROCESS

Name of Child:______Gender:______

Date of Birth: ______N.H.S No:______

Address: ______Tel: ______

______

______Mobile: ______

______

GP (name, address & telephone no): School (name, address & telephone no):

______

______

______

______

______

Names of those who hold Parental Responsibility?______

______

Please provide contact details if different from the child/young person:

Referred by:(Please state your name and job title)

______Date of Referral:______

______

______Signature: ______

______

Address______

______Tel No______

CHILDREN UNDER 7 YEARS:

1. Indicate below if there is a known or suspected eye problem and give further details below:

Squint(misalignment of the eyes, sometimes known as a ‘turn’ or ‘cast’)

Reduced vision

Nystagmus (uncontrolled to and fro movement of the eyes)

Refractive error (need for glasses)before age 7

Anyeye movement or binocular vision problem

2. Is there a family history of eye problems? Specifically, does the child have a first-degree relative (i.e. parent or sibling) or at least two second-degree relatives with one of the following conditions?

 A squint / turn / cast in the eye

 Amblyopia / ‘lazy eye’ (reduced vision in one eye, often treated by patching)

 Nystagmus

 Glasses needed from a young age (i.e. prior to 7 years old)

CHILDREN OVER 7 YEARS:

3. Most children of this age should be tested in the first instance by a high-streetoptician / optometrist. If particular visual symptoms persist after seeing an optometrist they may need to be seen by the Orthoptic service for further testing.

Please only refer if a child consistently complains of any of the following:

 Complains of blurred vision, or difficulty with adjusting focus from near to distance.

 Complains of double vision

 Complains of headaches or eye-strain

4. Do the parents or school have any concerns regarding their child’s eyes or vision? Please give details:

(note thatthe referral may not be accepted if it is outside the scope of headings 1, 2 or 3 above.)

5. Please provide details of whether the child/young person has a learning disability and/or an autistic spectrum disorder:

6. Please provide any further details you believe to be pertinent to the referral:

7. Consent to Referral

Yes No

Have you discussed this referral with the family/young person? 

Is the family/young person willing to attend the Eye Service? 

Professionals currently involved(Please add names and telephone numbers)

CAMHS  Educational Psychologist 

____________

Community Paediatrician  School Nurse 

____________

Occupational Therapist BST worker 

____________

Speech & Language Therapist MAPS worker 

____________

Physiotherapist Social Worker 

____________

Health Visitor  Other 

____________

SENCO  Other 

____________

Please specify any Child Protection Issues:

Please specify any risk concerns:

Please list any documentation you have attached to the referral:

______

______

THANK YOU FOR COMPLETING THE FORM

Please return to: Orthoptic Service, St. Albans Children’s Centre, Church Crescent, St. AlbansAL3 5JB

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