Wiltshire Portage Services – Referral Form

Please complete all boxes where possible and use block capitals(please circle where options)

Name of Child:

Date of Birth:
Date of Referral: / Male Female
First Language: English /Other please specify:
Names of Parent/Carers
Address with Postcode / Siblings – Names & Ages
Armed Forces Family. Yes No
Home Tel. No.
Work Tel. No.
Mobile Tel. No.
Email Address:
Diagnosis–please enclose copies of Assessment Reports/CAF Pre-Assessment or CAF.
Reason for Referral

General Practitioner – Name/Address/Telephone

Health Visitor – Name/Address/Telephone
Other Professionals – Consultants,Therapists,Social Workers, SEND workers – Name/Address/Telephone
Your Child’s Week / Morning / Afternoon
Monday
Tuesday
Wednesday
Thursday
Friday
How can Portage Help?
Referrer Name
Address & Telephone Number
Professional Signature / Date

Parent Agreement Signature

/ Date

Referrals to the Wiltshire Portage Services

Promoting Equal Opportunities throughout Wiltshire
This form should be used by all making Portage Referrals.
Parents may also refer their own child.
The following criteria should be met:
□The childis as young as possible or of pre-school age, and has at least 12 months before entering school.
□The child has a 50% developmental delayin at least two developmental areas,one of these must be cognition. (3 years of age or under - 30% developmental delay in two areas of development and one of these must be cognition).
or
□ A known Medical Diagnosis or Syndrome with delay anticipated as above
Additional information required you MUST include:
□Up to date report enclosed e.g. Paediatric, Health visitor or other Health Professional, indicating level of developmental delay
Or/Both
□CAF Pre- Assessment Form or CAF – indicating level of developmental delay.
Referrals received without the above paperwork will be returned to the referrer.
□The referral has been discussed with parents/carers and their signature obtained.
□The child’s parent/carer must agree to be available to meet with the Portage Home Visitor on a regular basis. This will usually be on the same day each week at a mutually agreed time.
Families who move within or into Wiltshire will normally continue to receive Portage.
Please return to appropriate Wiltshire Portage Service Office (please tick box)
□ForWiltshire Portage - Chippenham, Calne, Corsham, Malmesbury, Wootton Bassett, Lyneham, Devizes, Aldbourne, Marlborough, Pewsey, Tidworth, Ludgershall, Trowbridge, Melksham, Warminster, Westbury, Bradford on Avon and surrounding villages.
Please return to:Wiltshire Portage,
Kings Rise Children’s Centre, Pewsham, Chippenham, Wiltshire SN15 3SY Telephone: 07780 653888
□For South Wiltshire– Salisbury, Wilton, Wylye, Tisbury, Mere, Shrewton, Amesbury, Durrington, Larkhill, Bulford, Winterslow, Alderbury, Whiteparish, Downton, and surrounding villages.
Please return to:SalisburyPortageServiceSalisburyDistrictHospital, Salisbury,
Wiltshire SP2 8BJ Telephone: 01722 336262 ex 2495

For Office use only – Tick and date

□Acknowledgement letter to referrer / Date: / □Portage Offered Yes/No / Date:
□Letter to Family/placed on waiting list / Date: / □Assigned / Date:
□Initial Visit Made / Date: / □Discharged/Closed / Date:

Wiltshire Portage Referral Form 2014