Request for involvement
Communication Interaction Team
Version 3, December 2014 Not protectively marked
PLYMOUTH CITY COUNCIL
You may want to consider calling the Gateway or an Advisory Teacher for discussion prior to making a referral.
Please complete as much of the form as you can, ensuring that you have the signed consent of the young person’s parent or carer to share information, Please return to Children’s Integrated Disability Service, Plymouth City Council, Windsor House, Plymouth PL6 5UF Tel: 01752 305252
The Speech & Language Communication Need(SLCN) checklist must be included to validate area of need. Please include as much detail as possible in the comment boxes provided. Indicated by your checklist, which service do you feel you require at this stage? Please feel free to leave blank if you feel you would like us to make that decision.
☐Language needs☐SLCN Checklist Completed
Or
☐Social communication or autism spectrum needs
Parent and child details
Child's nameClickheretoenter name / DOBDate of birthEthnicityClickheretoenter ethnicity / First languageClickheretoenter language
Hospital numberClickheretoenter hospital no / Is this child looked after (LAC)? ☐Yes ☐No
Parent or carer name (1)Clickheretoenter name / DOBDate of birth
Parent or carer name (2)Clickheretoenter name / DOBDate of birth
AddressClickheretoenter address
Phone numberClickheretoenter phone no / Email addressClickheretoenter email address
Referrer details
SENCO Name Clickheretoenter SENCO name / SENCO SignaturePhone numberClickhereto enter phone number
School/Nursery/Children's Centre
EstablishmentClickheretoenter school etc / UPNEnter UPN / YearEnter yearIsthereaSENDPlan/Team Around Me/Any other Outcome Based Training? [Please attach] Yes☐ No☐
Does the CYP have a statement/EHC?
☐Yes☐No
Other services involved with this young person including supporting evidence (CAMHS, SALT, CDC, EP, MAST services)
Name / ContactName / Contact
Name / Contact
Name / Contact
Summary of strengths (Academic or other)
Summary of needs (including diagnosis if appropriate)
Outline actions taken to help young person so far and the impact
Actions:
Impact:
Outline the specific type of support and anticipated outcomes you would like FOLLOWING THIS referral
School/Settings Outcomes
Outcome 1)
Outcome2)
Outcome 3)
Parentor carer's view
Young person’s view
Additional information
Please supply as much additional information as possible including relevant reports from other agencies such as psychologist, therapist, paediatrician, audiologist, speech and language therapy etc.
The following information has been included (please tick)
☐SLCN Checklist☐Statement/Annual Review/EHC
☐Observational Information
☐IEP/Or other One page profile
☐Reports from other agencies involved
I understand that information is recorded about me/my child. I have had the opportunity to discuss the implication of this. Please tick one of the following and sign where appropriate.
1. I agree that personal information about me/my child may be shared between this organisation and other relevant organisations / Name
Signature of child/young person
Date
Signature of Parent/Carer
Date
2. I agree that personal information about me/my child may be shared between this organisation and other relevant organisations except:
/ Name
Signature of child/young person
Date
Signature of Parent/Carer
Date
I understand that the limitations may affect the service that is available. We will not pass on any information without consent, unless we are required by law or we have a statutory duty to do so in order to:
1. Protect you, or, 2. Prevent harm to someone else, or, 3. prevent or detect a crime
3. I do not want my personal information being passed to other organisation / Name
Signature of child/young person
Date
Signature of Parent/Carer
Date
The professional working with you and your child will talk to you explaining what information is held on your child, why it is held, why it is shared with other agencies and details about the law.
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