Early Intervention Team

EARLY INTERVENTION TEAM

HSE LHO DUBLIN NORTH CENTRAL

Please fill in using block capitals.

Surname: / First Name:
Address:
Date of Birth: / Age at referral: / Sex:
Mother’s Name: / Father’s Name:
Mother’s Address (if different to above) / Father’s Address (if different to above)
Telephone No (landline and mobile) / Telephone No (landline and mobile)
Biological parents relationship
Married □ Separated □ Divorced □ Single □ Co-habiting □ Widowed □
Child’s Carers
Both parents □ Mother alone □ Other relatives □ Foster parents □
Mother plus another □ Adoptive parents □ Residential unit □ Father plus another □ Grandparents □ Other (Please specify):
Language(s) spoken at home Ethnicity:
Preschool / Contact number
GP / Contact number
Diagnosis:
Relevant developmental/sensory/medical history:
Indicate the skill areas in which the child presents with difficulties.
Please specify by providing examples.
Speech □
______
Language/Communication □ ______
Social interaction □
______
______
Fine-motor □
______
Gross-motor □______
Balance / Co-ordination □
______
______
Cognition / Learning □
______
______
Behaviour □
______
______
Attention / Concentration □
______
______
Play □
______
______
Toileting □
______
______
Feeding □
______
______
Dressing □
______
______
Sensory processing □
______
______
Has the child seen anyone in connection with these difficulties?
Profession / Name / Telephone
Public Health Nurse
Paediatrician
Speech and Language Therapist
Physiotherapist
Psychologist
Occupational Therapist
Area Medical Officer
Audiologist
Child Psychiatrist
Ophthalmologist
Social Worker
Other
Does the child have any appointments coming up? Yes □ No □
Please specify______
Has the child been recently referred to another service or attended this service in the past? Yes □ No □
Please specify______

Please attach ALL relevant medical/professional reports to the referral. Failure to do so will delay processing of the referral.

Parental Consent
I have given permission for my child to be referred to the Health Service Executive Early Intervention Team. Yes □ No □
I consent to sharing of professional reports/correspondence relating to my child between professionals (e.g. nurse, doctor, school, therapist etc.) Yes □ No □
Mother’s/Guardian signature / Father/Guardian signature
Date / Date
Are both parents aware of this referral? Yes □ No □
Referred by / Please return by post to:
Secretary
Early Intervention Team
HSE, LHO, Dublin North Central
44 North Great George’s Street,
Dublin 1
Tel: 01 8146 197
Fax: 01 8146 196
Position
Agency/Address
Contact no:
Date:

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