Home
Services
Guides
Forms
NCMP Letters
Contact Us

A service provided by

01753 373464

0800 7723578

Children Educated at Home

Home
Children Educated at Home

Children Educated at Home

PLEASE COMPLETE ALL SECTIONS IN THIS FORM

Child's Information

Child's Name *

Email *

Address *

DOB *

Phone Number *

NHS Number (if know)

GP surgery your family is registered with *

Physical Health This section will ask about any medical conditions or disabilities your child has or is being investigated for.

Does your child have any of the following medical conditions requiring medication? Asthma Epilepsy
Allergies Diabetes

Does you child have a special educational need or disability, sometimes known as SEND? Yes No

If you have answered yes to any of the above, do you have a health care professional supporting your child's needs? Yes No Maybe

Please provide the name of any healthcare professionals involved in your child's care.

Is your child registered with a dentist?
Yes No

Has your child see an optician within the past year?
Yes No

Are you concerned about your child’s hearing or speech?
Yes No

Does your child have problems with daytime wetting or soiling?
Yes No

Does your child have problems with night time bed-wetting?
Yes No Maybe

Is your child up to date with all of their immunisations?
Yes No
We have chosen not to immunise

Do you have any concerns with regards to your child’s growth and development?

Healthy Lifestyles

This section will ask how healthy you think your child is.

Would you consider your child to have a healthy diet?
Yes No Maybe

Would you consider your child achieves enough daily activity?
Yes No Maybe

Are you able to access local activities?
Yes No

Does your child have a bedtime routine and good quality sleep?
Yes No Maybe

Do you have any concerns about your child's growth?

Do you feel you child is a healthy weight?
Yes
No, I think they are underweight
No, I think they are overweight

Do you feel your child worries about their appearance?

Would you like any advice or support from your public health nursing team? Yes, individual advice or support
Yes, to join a parent group
No

Emotional Health

This section will ask about any emotional wellbeing needs or mental health concerns your child has or is being investigated for.

Do you have any concerns with your child’s behaviour?

Do you have any concerns about your child’s emotional wellbeing or mental health?

If you have answered yes to any of the above, do you have a health care professional supporting your childs' needs? Yes
no
Maybe

Please provide the name of any healthcare professionals involved in your childs'care.

Would you like any advice or support from your public health nursing team? Yes, individual advice
Yes, to join a parent group
No

Community Safety

This section will ask how safe you feel your child is in the community, at school and at home.

Does your child have a friend or friends they can spend time with?
Yes No
Maybe

Do you feel your child is safe in your local community?
Yes No
Maybe

Is your child aware of road safety?
Yes No
Maybe

Is your child aware of water safety?
Yes No
Maybe

Do you or your child feel they are being bullied?

Do you help to keep your child safe online?
Yes No
Maybe

Does your child have a trusted adult at school or in the community to talk to if they have any worries or concerns? Yes No
Maybe

Would you like any advice or support from your public health nursing team? Yes, individual advice
Yes, to join a parent group
No

Family Health

This section asks about any family needs that may impact your childs' health and wellbeing. The questions may feel intrusive but we are asking to ensure we can provide the best support for your childs' wellbeing, there is no judgement made about your families needs. All answers are confidential unless we feel your child is at risk of abuse

Does anyone in the family home have a physical disability or mental health need? Yes No

Would you consider your child to be a young carer?
Yes No
Maybe

Do you feel your child is exposed to any ongoing conflict within the family environment? Yes No
Maybe

Would you like an help or support from your public health nursing team?

Contact Us

Public Health Nursing 4 Slough
224 Berwick Avenue,
Slough, SL1 4QT
Telephone: 01753 373464 / 0800 7723578
Contact Us Form

Useful Links

School Nursing Referral
Health Visiting Referral
Safeguarding, Modern Slavery & Human Trafficking Declaration
Slough Advice Centre
Privacy Policy

Follow Us

Disclaimer

This website is designed for information purposes only and is not designed to provide specific medical advice or professional services. If you have a health problem you should consult your doctor or other suitably qualified health professional and obtain advice and treatment from them that takes into account your specific symptoms.

The content of this website was reprinted with permission from Lincolnshire Community Healthcare Trust. All rights reserved.