REFERRAL FOR A NOTTINGHAM CITY SPECIALIST SUPPORT SERVICE FOR CHILDREN IN THE EARLY YEARS

Information for parents

Everyone working for the Local Authority and the National Health Service has a legal duty to keep information about you and your child confidential. All services working with you and your child need up to date information. We only ever use or pass on information if there is a real need to do so.

  1. ‘PARENTAL CONSENT – Please sign the form so that we can share the information

Can Panel share the information in this form with relevant colleagues? / Yes / No
Signature(A referral cannot be accepted without a parental/legal guardian signature) / Date:
2. CHILD’S DETAILS (please print)
Given Name(s): / Legal Last Name:
Date of Birth: / Any Former Last Name:
Male Female / Preferred Last Name:
Address:
Post Code:
Parents’/Legal Guardian(s)’ Names (please indicate everyone who has parental responsibility):
Language Spoken:
Interpreter Needed: Yes No / Ethnicity:
Telephone Number/s: / Home: / Work: / Mobile:
e-mail address:

Please provide any Health and Safety information that is relevant when working in the home

EARLY YEARS PROVISION
Does the child attend any early years care or educational setting? / YES / NO
NAME, ADDRESS AND TELEPHONE NUMBER OF SETTING:
Notification to the Local Authority (Section 332)
This will be centrally logged – no action will be taken without further evidence or request for services, etc. / Panel to decide the most appropriate service(s) to support the child
Support Service for the Deaf and Hearing Impaired / Educational Psychology Service (EPS)
Support Service for Visual Impairment / Transition Support (Autism/LST)
Early Years Foundation Stage, Special Educational Needs and Disabilities Worker (EYFS SEND Worker)
(formerly PORTAGE)
Is the child subject to any order under childcare legislation?
(Is the child a ‘Child in Care’ of a Local Authority?) / YES / NO
Has a Common Assessment Framework (CAF) been initiated? / YES / NO
Does the child have Education Health and Care Plan (EHC)? / YES / NO
Team Around the Child Meeting? (TAC)
Please state future dates here: / YES / NO
Is the child known to Social Care? If yes, please give details / YES / NO
Does the child have a clinical diagnosis? If yes, please give details / YES / NO
REFERRED BY: / Completed form
to be returned to:
Name:
Profession:
Address:
Post Code:
Telephone Number:
e-mail:
Signature:
Date: / Lidia Sawula-Rhodes, Administration Assistant
Nottingham City Council
Children’s Services
Glenbrook Management Centre,
Wigman Road,
Bilborough,
Nottingham
NG8 4PD
Telephone: 0115 876 5829
Secure Email:

Agency / Name / Contact Number
Please complete the sections below providing evidence of the child’s development.
Attach relevant documents e.g. reports, audiograms, clinic letters, Individual Provision Maps, Graduated Approaches etc., as appropriate.
Summarise the child’s additional needs.
Provide evidence that the child meets the criteria of the service you are referring for (please see criteria leaflet attached)
How does the child communicate and interact with others?
Describe the child’s level of physical development
What does the child like to do? How does he or she play?
How does the child take part in eating, drinking, dressing and toileting?

April 2015