Referral form

Children or Young People's Continuing Care

Step 1 of 6

16%

Consent for Sharing Information

Please note referrals can only be accepted if consent has been given

Is the child or young person under the age of 16?(Required)

Yes

Has the child been assessed as Gillick competent and given consent?(Required)

Yes

Has the person with parental responsibility consented to the referral?(Required)

Yes

Consent is required to proceed.

Is the young person able to consent?(Required)

Yes

Have they provided their consent?(Required)

Yes

Consent is required to proceed.

Has the MCA and BI decision been taken(Required)

Yes

Mental Capacity assessment/Best Interest decision must be completed to continue.

Child or Young Person’s Details

Name(Required)

First Last

Preferred name

First

Date of birth(Required)

DD slash MM slash YYYY

NHS Number(Required)

Address(Required)

Street Address City County Post Code

Gender at birth(Required)

Male

Female

Please state what gender you identify as now if different from birth

First language (if not English)

Translator needed:

Yes

Other communication support needed:

Yes

Details of communication support needed:

Person(s) with parental responsibility

Parental responsibility held by(Required)

Address(Required)

Street Address City County Post code

Contact phone number(Required)

Email(Required)

Relationship(Required)

NB. details of one parent only are acceptable, but it must be the parent with responsibility.

Primary contact 1 (optional)

Please add Primary Contact below if person with Parental Responsibility is not the primary contact.

Name

First Last

Address

Street Address City County Post code

Contact phone number

Relationship

Primary contact 2 (optional)

Name

First Last

Address

Street Address City County Post code

Contact phone number

Relationship

GP Details

Name and Address of GP Practice(Required)

Street Address City County Post code

Name of GP(Required)

Local Authority:(Required)

Specify Other Authority(Required)

Is child or young person in receipt of Universal or Specialist Health services?(Required)

Yes

Name of service(Required)

Support received(Required)

Frequency of support(Required)

Tick the box to add another service (2)

Add another +

Name of service (2)(Required)

Support received (2)(Required)

Frequency of support (2)(Required)

Tick the box to add another service (3)

Add another +

Name of service (3)(Required)

Support received (3)(Required)

Frequency of support (3)(Required)

Tick the box to add another service (4)

Add another +

Name of service (4)(Required)

Support received (4)(Required)

Frequency of support (4)(Required)

Tick the box to add another service (5)

Add another +

Name of service (5)(Required)

Support received (5)(Required)

Frequency of support (5)(Required)

Tick the box to add another service (6)

Add another +

Name of service (6)(Required)

Support received (6)(Required)

Frequency of support (6)(Required)

Tick the box to add another service (7)

Add another +

Name of service (7)(Required)

Support received (7)(Required)

Frequency of support (7)(Required)

Tick the box to add another service (8)

Add another +

Name of service (8)(Required)

Support received (8)(Required)

Frequency of support (8)(Required)

Tick the box to add another service (9)

Add another +

Name of service (9)(Required)

Support received (9)(Required)

Frequency of support (9)(Required)

Tick the box to add another service (10)

Add another +

Name of service (10)(Required)

Support received (10)(Required)

Frequency of support (10)(Required)

Tick the box to add another service (11)

Add another +

Name of service (11)(Required)

Support received (11)(Required)

Frequency of support (11)(Required)

Tick the box to add another service (12)

Add another +

Name of service (12)(Required)

Support received (12)(Required)

Frequency of support (12)(Required)

Medical History

Is the child’s or young person’s health deteriorating and are they approaching end of life?(Required)

Yes

Please provide details of diagnosis and prognosis(Required)

Has child or young person had any hospital admission in the last 12 months?(Required)

Yes

Provide details(Required)

Does the child or young person have any known medical conditions/diagnosis?(Required)

Yes

Provide details(Required)

Please provide an overview of the child or young person’s health needs

Domain

Please include the following: diagnosis, summary of primary health need, current health provision and supporting evidence, including information from other professionals involved.

Breathing – identified needs?(Required)

Yes