Hertfordshire Children’s Continuing Healthcare

Nascot Lawn Admission Panel

INITIAL REFERRAL & ASSESSMENT FORM

Child’s Name: / Date of Birth:
Address:
Postcode: / Telephone No:
Mobile:
Parents/Carer Details:
Family Structure/Genogram:
Diagnosis / Problems:
· 
Family understanding of condition:
Reasons for referral to Nascot Lawn Admission Panel (summary):
Details of health/CSF support currently provided to family:


Key Health/CSF Professionals involvement

Health Key Worker Name: / Health Key Worker Address:
Health Key worker Tel. No:
CSF Key worker
Name: / CSF Key Worker Address:
CSF Key Worker Tel. No:
GP: / GP Address:
GP Telephone No:
GP confirmed within a Hertfordshire Primary Care Trust boundaries / YES/NO (Delete as appropriate)
Paediatrician (HPT/WHHT): / Paediatrician Address:
Paediatrician Tel.
No:
School/
Nursery: / School/Nursery Address:
School/Nursery Tel.
No:
Health Visitor/
School Nurse: / HV/SN Address:
HV/SN Tel.
No:
Other Professional Involvement
Professional group: / Name: / Tel. No: / Contact Address:


ACTIVITIES OF LIVING ASSESSMENT

Sleeping: / Eating:
Elimination: / Hygiene:
Medications: / Breathing:
Communication: / Mobility:
Play & Activity: / Pain/discomfort:


Daily activities

(times do not need to be precise, but should give a clear indication of the child’s usual pattern of activities/care needs)

Timetable of Daily Routine / Please indicate with ü where help/support is required
Time / Activity
0000
0100
0200
0300
0400
0500
0600
0700
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300


In summary……….

What sort of care are you seeking on behalf of the child? Please give as much detail as possible.
Day Care (Only available for pre-school children – one day per week) / Overnight Care (Weekdays)
Overnight and Day Care/Weekends / Holiday Respite
Name of Assessor/s:
Date of this assessment:
Date of Nascot Lawn Admission Panel at which this assessment is to be presented:
Nascot Lawn Admission Panel Decision
Admission Criteria Met? / YES/NO (Delete as appropriate)
Details of package to be provided:
Funding Split – CSF/Health? If applicable
Panel decision to be communicated to parents verbally by:
Panel decision to be communicated to parents in writing by:

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