MEATH (6-18years) CHILDDEVELOPMENT TEAM
REFERRAL FORM (Nov 15)
Please attach any other relevant reports with this referral
Child’s Name:______Date of Birth: ______
Address:______Nationality:______
______GP:______
______Medical/GP Card No. ______
Gender: Female □ Male □ ID Database□ P and S Database □
Child’s first language______Interpreter needed yes □ no □
What other languages are spoken at home______
Parent/Legal Guardian and Family Information
Mother’s name:______Father’s name:______
Address:______Address:______
______
Who is/are the child’s legal guardian ______
Phone No: ______Mobile:______
E-mail: ______/ Phone No: ______
Mobile:______
E-mail: ______
Do you consent to receive information by e-mail?Yes_____No______
Do you consent to receive appointments by e-mail?Yes_____No______
Disability/Diagnosis Information
Has a diagnosis been made, yes no. If yes, please state diagnosis and who made it? ______
If referred for a diagnostic assessment do you think your child has a specific condition? eg Autism, learning difficulties etc______
What are your main concerns about your child? Give examples. ______
______
______
______
How long have these problems been a concern to you?______
______Birth History______
History of Medical Health______
______
Vision or Hearing – Do you have any concerns? Have they been tested?______
______
List any medication your child takes______
Eating Drinking- please describe any difficulties experienced with eating and drinking ______
______
Expressive Language – describe any difficulties experienced in talking/ communication with others_____
______
______
Receptive Language – describe any difficulties in listening and understanding what others say______
______
Self Care – describe any difficulties with bathing dressing toileting etc______
______
Does your child receive nappies from the HSE ? ______
Social interaction / Play /Leisure /Mixing with other children– describe any difficulties ______
______
______
Physical Skills – describe any difficulties with movement, coordination, pencil skills etc______
______
Behaviour – Describe any difficulties with behaviour______
______
______
Are any of the following present?
Verbal/ Physical Aggression □Anxiety□ Restrictive Interests □
Attention /concentration difficulties□Obsessive behaviour□Hyperactivity □
Does not like change in routine □Self Injury□Withdrawn/ aloof□
What might cause or start these behaviours______
______
______
Educational/Other Services Information
School______Address______
Name of Principal______Telephone No.______
Does the child have a Special Needs Assistant Resource teaching Learning support
What health services / groups, therapies, hospitals or other does/did the child attend (please state whether currently attending or attended in the past)?
Medical Consultants:______
______
Psychiatry /CAMHS______
Occupational Therapy______
Physiotherapy______
Speech and Language Therapy______
Psychology______
Social work______
Other______
______
Referral Information What Services/ therapies does the child need most at this time?
1. ______
2. ______
3. ______
REFERRER’S DETAILS
Name:______Date of referral: ______
Address:______Relationship/Agency: ________
______
Phone:Work ______Mobile______
Signature: ______
Please add any further information that you feel is relevant:
Parents consent:
I / We consent to the referral of ______to the Meath Children’s Disability (6-18 years) Service. We give permission to have all relevant reports on our child released to the Service and for contact to be made with the school or other agencies if necessary. Where respite care is being considered relevant information can be forwarded to the HSE respite partners. I / We understand that information will be shared at the children’s team meetings and be held on computer records.
Signature: ______Date: ______
Signature: ______Date: ______
The referral will be accepted with one signature, but should if possible, be signed by both parents or legal guardians.
Additional information /parents comments:
Please return the referral form with relevant reports to:
Penny O’Connell
Meath Children’s Disability, Service Coordinator,
Bailis Resource Centre,
Johnstown,
Co. Meath.Any queries to: Tel. No. 046 9091400
OFFICE USE ONLY:
Received by Co-ordinator: ______Date: ______
Date discussed at Team meeting: ______Date: ______
Not suitable for service: ______Date: ______
Returned to: ______Date: ______
Referred on to: ______Date: ______
More information required: ______Date: ______