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Referral form

Home/Your health/PHC/Continuing care/Referral form
Referral formAnnabelle Clissold2022-07-26T15:49:48+01:00

Children or Young People's Continuing Care

Step 1 of 6

16%
NHS Dorset

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)
Has the child been assessed as Gillick competent and given consent?(Required)
Has the person with parental responsibility consented to the referral?(Required)

Consent is required to proceed.

Is the young person able to consent?(Required)
Have they provided their consent?(Required)

Consent is required to proceed.

Has the MCA and BI decision been taken(Required)

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

NHS Dorset

Child or Young Person’s Details

Name(Required)
Preferred name
DD slash MM slash YYYY
Address(Required)
Gender at birth(Required)
Translator needed:
Other communication support needed:

Person(s) with parental responsibility

Address(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
Address

Primary contact 2 (optional)

Name
Address

GP Details

Name and Address of GP Practice(Required)
Is child or young person in receipt of Universal or Specialist Health services?(Required)
Tick the box to add another service (2)
Tick the box to add another service (3)
Tick the box to add another service (4)
Tick the box to add another service (5)
Tick the box to add another service (6)
Tick the box to add another service (7)
Tick the box to add another service (8)
Tick the box to add another service (9)
Tick the box to add another service (10)
Tick the box to add another service (11)
Tick the box to add another service (12)
NHS Dorset

Medical History

Is the child’s or young person’s health deteriorating and are they approaching end of life?(Required)
Has child or young person had any hospital admission in the last 12 months?(Required)
Does the child or young person have any known medical conditions/diagnosis?(Required)
NHS Dorset

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)
Provide detail for the child or young person’s needs and you may wish to consider the following prompts as guide:

• Does the child/ young person need inhalers/nebuliser?
• Do they need antibiotics all the time to prevent infections?
• Do they require chest physio?
• Do they require oxygen? If so, are they oxygen dependent?
• Are they ventilated? If so for how many hours per day and would there be a risk of harm if ventilation were to be disconnected?
• Does the child/young person need suctioning, if so approximately how many times per day and/or night? Is suctioning oral or nasopharyngeal?
• Does the child / young person have frequent chest infections?
• Does the child or young person have any underlying conditions which may increase the likelihood of chest infections?
• Does the child or young person have an artificial airway and is this stable?
Eating & Drinking – identified needs?(Required)
Provide detail for the child or young person’s needs and you may wish to consider the following prompts as guide:

• Does the child/ young person eat orally, or they fed via a gastrostomy, peg or nasogastric tube?
• Are they able to eat independently or do they require help with feeding? If so, is feeding complex or lengthy?
• Do they have reflux or vomit frequently?
• Does the child or young person have identified swallowing issues or a diagnosis of dysphagia?
• If the child or young person has a gastrostomy, PEG etc is this problematic e.g., does it block frequently? Is it frequently infected or does it bleed? Does the child/young person pull it out?
• Does the child/young person struggle to absorb their food?
• Does the child or young person have a recognised eating disorder?
• Do they need a specialist diet plan?
• Are they under/overweight?
• What is their most recent weight or growth centile?
• How are their needs being addressed and have these measures been effective?
Mobility – identified needs?(Required)
Provide detail for the child or young person’s needs and you may wish to consider the following prompts as guide:

• Is the child or young person able to weight bare either independently or with support?
Do they have any functional movement of their hands?
• Do they have issues with bone density, skin or jerky movements that affect the way carers move them?
• Is the child or young person able to assist with transfers or repositioning?
• How many care givers are required to support with transfers or repositioning?
• Does the child or young person require night turning or repositioning at night?
• Does the child or young person require any equipment to assist with their mobility needs? If so, please detail?
• Do they have a physio program, if so, how long does this take?
• What health intervention has been advised? Is this helping, if not reasons why?
• Which medical professionals are monitoring this condition?
• How often are they reviewed by a medical professional in relation to their mobility needs?
Continence & Elimination – identified needs?(Required)
Provide detail for the child or young person’s needs and you may wish to consider the following prompts as guide:

• Is the child /young person continent?
• Do they have urine or faecal incontinence?
• Is the child or young person aware of their elimination needs?
• Do they suffer from frequent urine infections or constipation or diarrhoea? If so, what intervention is required to manage these?
• Do they need stoma’s/catheters or medical intervention to control their elimination needs?
• Does the child or young person require dialysis? Advice and treatment so far? Has this helped? If not, please give reasons. Which medical professionals are monitoring this condition?
• How often are they reviewed by a medical professional in relation to their continence and elimination needs?
Skin & Tissue Viability – identified needs?(Required)
Provide detail for the child or young person’s needs and you may wish to consider the following prompts as guide:

• Does the child/ young person have a diagnosed skin condition?
If so, what treatment/medical advice has been given?
Has this helped? Reason why it has not helped.
• Is the child or young person at increased risk of skin breakdown?
• Does the child or young person currently have any open wounds or pressure sores?
-If so, does the child/young person need specialist dressings?
-Does the carer need specialist advice and training to do the dressings?
• Does the child require the provision of pressure relieving equipment to maintain skin integrity?
• Does the child or young person require regular turning / repositioning to maintain skin integrity?
If so, what is the frequency of this?
• Do they need any special medication/creams to manage an identified skin condition, prevent infection, skin breakdown?
• Which medical professionals are monitoring this condition?
• How often are they reviewed by a medical professional in relation to their skin and tissue viability needs?
Communication – identified needs?(Required)
Provide detail for the child or young person’s needs and you may wish to consider the following prompts as guide:

• Is the child or young person able to express their basic needs e.g., hunger, pain?
How do they do this? For example, do they use PECS, eye gaze, body language, signing BSL / Makaton assistive technology?
• Is their communication effected by their mood, tiredness, sensory stimuli etc?
• What support have they had so far to develop their communication?
-Is this support helping?
• Please give reason if support not helping. Which medical professionals are monitoring this condition?
• How often are they reviewed by a medical professional in relation to their communication needs?
Drug Therapies & Medication – identified needs?(Required)
Provide detail for the child or young person’s needs and you may wish to consider the following prompts as guide:

• Does the child require regular medication for the management of an identified physical or mental health condition?
If so, what route is this medication administered by? E.g., oral, rectal, injection, gastrostomy.
• Can the child/young person take their prescribed themselves or does this need to be administered?
• Is the child or young person compliant with their prescribed medications?
If not, how do carers ensure that medication is administered?
• Do they require medication in the night?
• Do they require emergency or PRN medication?
If so, how often?
• Does the child/young person need to be hospitalised because medication has not been effective, if so, how often?
• Does the carer need extra training to give medication?
• How often is the medication reviewed by a qualified medical practitioner?
• Have there been any recent changes to prescribed medications? If so please provide details.
Psychological & Emotional Needs – identified needs?(Required)
Provide detail for the child or young person’s needs and you may wish to consider the following prompts as guide:

• Does the child or young person have a diagnosed mental health condition?
If so, what impact does this have on the child or young person?
What support has been offered so far? Has this been helpful? If not please give reason.
• Are they currently open to any mental health services e.g., CAMHS/ ID CAMHS / PSYCHIATRY / PSYCHOLOGY?
• Does the child attend school/college? Do they engage with activities?
• Has there been a significant deterioration in the child’s engagement, social functioning and self-care?
If so, can this deterioration be attributed to age, peer pressure, recent event or stressful situation?
Which medical professionals are monitoring this condition? How often are they reviewed by a medical professional in relation to their psychological and emotional needs?
Seizure – identified needs?(Required)

Provide detail for the child or young person’s needs and you may wish to consider the following prompts as guide:

• Has the child been diagnosed with epilepsy?
If so, what type of seizures do they experience e.g., tonic clonic, absence or focal seizures and what is the frequency of these?
Are seizures linked to an event e.g., temperature, fall etc.
• Is the child/young person’s epilepsy medication needing regularly review, if so, how often and by who?
• Is the child/young person prescribed emergency medication?
If so, how often do they need it?
• How often does the child/young person need hospital admission due to seizures?
• Has the child/young person had a VNS or other surgical seizure control procedure?
• Does the child need care in the night due to seizure management, if so, how often?
Which medical professionals are monitoring this condition?
How often are they reviewed by a medical professional in relation to their seizures?
Challenging Behaviour – identified needs?(Required)
Provide detail for the child or young person’s needs and you may wish to consider the following prompts as guide:

• Does the child or young person present with behaviours that challenge?
-If so, please specify types of challenging behaviour and frequency of this?
-What are the risks to the child/young person or others as a result of this behaviour?
• Is the child’s behaviour predictable or are there identified triggers, e.g., when they experience something new, if they have not understood events planned?
• Does the child or young person use their behaviour as they as a way to communicate?
• How has their behaviour been addressed?
• Has any health or behaviour intervention been helpful?
• Is a specialist health team currently involved or have they previously been involved? If not please give reasons.
• Is the child or young person currently at risk of exclusion from school or home due to their behaviour?
Which medical professionals are monitoring this condition?
How often are they reviewed by a medical professional in relation to their behavioural needs?
Please note the weighting of challenging behaviour is unlikely to be a High or greater if specialist health involvement is not being currently offered and a current health assessment and plan is not available to the CCG.

Social Care

Is child or young person in receipt of services from Social Care?(Required)

Education

Is child or young person attending school, college, or an alternate education provider?(Required)
Does the child or young person have special educational needs?(Required)
Does the child have an Education, Health and Care Plan or SEND statement?(Required)
EHCP or SEND documents will need to be uploaded in the supporting documents section at the end of the form.

Details of referral

DD slash MM slash YYYY

Other Support

Are there any other individual or Organisations who support the child or young person?(Required)
Tick the box to add more support (2)
Tick the box to add more support (3)
Tick the box to add more support (4)
Tick the box to add more support (5)
NHS Dorset

Supporting Information

Supporting Evidence

Please attach any relevant assessments / clinic letters and associated documents to support this referral (Evidence must be current)
Accepted file types: pdf, doc, docx, Max. file size: 256 MB.
Referrals will not be processed without the consent form. Please ensure this accompanies the referral form.
Accepted file types: pdf, doc, docx, Max. file size: 256 MB.
If the referrer has confirmed BI has been completed above.
Accepted file types: pdf, doc, docx, Max. file size: 256 MB.
If child or young person have a SEND or EHCP statement. It is mandatory document is uploaded.
Drop files here or
Max. file size: 256 MB.
    NHS Dorset

    Declaration

    I have provided the above information and supporting evidence for this child to undergo a pre-assessment checklist completed by a nurse assessor. This information and supporting evidence is accurate and up to date to the best of my knowledge.(Required)
    I confirm I am a health or social care professional(Required)
    DD slash MM slash YYYY
    (NMC, HCPC, Social Work England)
    Address
    Contact details
    Telephone: 01305 368900
    E-mail
    Call 111, if it is not an emergency
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