STAFFORDSHIRE

EARLY YEARS FORUM referral form

FAO: SEND Locality Manager, SEND Assessment and Planning Service (EHC) at the appropriate district office (addresses at the end of this form)

A. DETAILS OF CHILD

Name: / Date of Birth:
Age:
Address:
Name of all person/s with parental responsibility:
Mother’s Name:
Address:
(if different from above)
Father’s Name:
Address:
(if different from above)
Other / Carer Name:
Address:
(if different from above)
Relationship to child: / First language:
Telephone No:
Email:
Parental Responsibility: Yes / No
First language:
Telephone No:
Email:
Parental Responsibility: Yes / No
First language:
Telephone No:
Email:
Parental Responsibility: Yes / No
Current Educational Setting:
Address:
Telephone Number: / Date admitted:
Number of sessions::
LAC: Yes / No
If yes, name of Local Authority: / Name of Social Worker:
Telephone No:
Email:

Please note: This form should be completed in full and supporting documentation attached as indicated in Part F. Incomplete forms may be returned.

B. Reason for referral

Diagnosis / Area(s) of Concern:
General Practitioner:
Contact Number: / Health Visitor:
Contact Number:
Consultant Paediatrician:
Contact Number: / Hospital Unit Number:

C. Other Information

Agencies Involved (please give names
and contact numbers):
Pre-school Provision:
Doctor/paediatrician:
Speech and Language Therapist:
Physiotherapist:
Occupational Therapist:
Social Worker:
Early Years Area SENCo:
Child & Adolescent Mental Health Service:
Dietician:
Learning Disability Service:
Local Support Team:
Hearing Impairment Team / Visual Impairment Team
Physical Disability Support Service:
Other Agencies (e.g. EP):
Summary of Child:
Any other information:

D. Referrer Information

As the referrer you may be asked to be the parental contact for this family, at least for the first forum, providing a link between the forum and the parents/carers and sharing forum outcomes.

Referred by: ………………………………………………………………….
Role: …………………………………………………………………………
Address ......
………………………………………………………………………………………………..
………………………………………………………………………………………………..
Post Code: ………………………………………
Telephone number: ……………………………………………………….
Email: ……………………………………………………………………….

E. Parental Consent

Parent consent:
The parent EYF leaflet has been discussed. I confirm that I consent to my child being referred to the Early Years Forum. I understand that relevant information may be shared with other staff within health, education and social care services and that information may be kept in a secure electronic file. I understand that I may see this information on request.
Signature……………………………………………………………………………….
Name…………………………………………………………………… (please print)
Parents’/carer’s preferred method of communication:
e.g. Email / Telephone / Post

Forms without a parental signature will be returned

F.Checklist of Evidence

This ensures that sufficient information is available to allow the Early Years Forum to proceed with the referral; to understand the nature of the child’s difficulties, what has already been put in place, and the child’s response to this and the purpose of the referral.

Please attach information from your own service plus any of the following information / evidence (as appropriate and available):-

 Early Years Stage profiles / other indicators of skill levels

 Individual Education Plans (IEPs) / evidence of support in targeted areas

 Early Help Assessment

 Schedule of Growing Skills assessment, Bayleys, Griffiths assessments etc.

 CDC reports

 Information from other professionals involved with the child where available

 Other ………………………………………………..

Please notify other services who are involved of your intentions to refer to the Early Years Forum

EYF Referral Form (August 16)Page 1

Stafford and South Staffs:

The Kingston Centre

Fairway

Stafford

ST16 3TW

Lichfield and Cannock:

The Old Library

Bird Street

Lichfield

WS13 6PN

Newcastle and Moorlands:

Seabridge Centre

Ashway,

off Seabridge Lane,

Newcastle,

ST5 3UB

East Staffs and Tamworth:

Burton Education Centre
Grange Street
Burton-on-Trent

DE14 2ER

EYF Referral Form (August 16)Page 1