To make a referral send this form to: Specialist Children’s Service

Referral Centre, The Wood Street Health Centre, 6 Linford Road,

Walthamstow E17 3LA

Telephone 020 8430 7890/7901 Fax: 020 8430 7801 North East London Community Services

SPECIALIST CHILDREN’S SERVICE REFERRAL FORM

Is this referral form accompanied by a completed CAF Form Yes No
If Yes, please attach completed CAF form.
If No, Did you complete Pre CAF Form? Yes No
If Yes, please attach completed Pre CAF Form.
If completed Pre CAF or CAF Form is not accompanied with this form we will not process this referral.
Child’s Name / M F / Date of Birth
Child’s Address
Postcode / School / Nursery / Children Centre
Telephone / Language
Interpreter required Y N
Mobile Phone / Religion
E-mail address / Ethnicity
NHS Number / Social Services ISIS No / WhippsCrossHospital No
Who has parental responsibility?
Parent / Carer’s Name / Relationship
Address
Postcode: / Telephone
GP Name / GP Address / Surgery
Other Professionals / Agencies involved
Brief Medical Information i.e. birth history, current health issues, medication, admission/discharge details:
Reason for referral and brief explanation of concerns including specific functional difficulties, health or social needs (Please attach relevant reports)
Developmental History and Milestones:
Age of smiling: / Age of sitting:
Age of walking: / Age of first words:
Date of hearing test: / Date of eye test:
Comments:
Please tick the boxes below to indicate the services you would like this referral to be passed to: (See referral criteria booklet)
Children’s Community Nursing Team / Community Paediatrician / Social & Communications Clinic
Child Development Team / Physiotherapy / Special Immunisation Clinic
Children with Disabilities Social Work Team / Portage / Speech & Language Therapy
Occupational Therapy
Parent’s / Carer’s concerns and expectations:
Family History (including family composition, support network, others with illness or disability in the family):
Social History (including any child protection concerns):
Other relevant information:

Information Sharing Consent:

Please note that referrals made to a specific team within the Specialist Children’s Service are often shared with other teams and agencies (e.g. Education, Children’s Centres, Social Services and Health Services), so that they can help us to identify the services your child may need.
Occasionally information about your child may be requested from other agencies or sent to them in order to facilitate quality of care for your child.
I understand the information that is recorded on this form will be stored and used for the purpose of providing services to:
Myself
This infant, child or young person for whom I am a parent
This infant, child or young person for whom I am a carer
I have had the reasons for the referral to the service and information sharing explained to me and I understand those reasons.
I agree to the sharing of information between the services: Yes  No
Comments (if any):
Signed: Name: Relationship: Date:
Referrer’s Name: Referrer’s Designation
Referrer’s Address:
Referrer’s Telephone No: Date of referral:
Office Use Only
Name and designation of receiver: / Date:
SCS ID:
Passed to:

This referral will only be accepted if all sections of both pages are completed.

Please use capital letters and black ink and continue on Page 2

May2010, v3.0