School Health Team Referral

Child/Young person Name: *

Address *

DOB *

Email *

School:

Child in Care
Yes No

Is an Interpreter required:
Yes No

Education Inclusion Service*

Youth Services *

Social Care *

Speech & Language *

Educational Psychologist *

Youth Offending Team *

CAMHS *

Occupational Therapist/Physiotherapist *

Virtual School *

AikSaath *

Counselling/OtherMental Health *

Medical Professional*

Child Development Team *

Behaviour Support *

Dietician*

Other *

There are no professionals supporting this child/young person

Any additional family health or wellbeing needs Yes No

ANY ADDITONAL INFORMATION FOR STUDNETS WITH SPECIAL EDUCATIONAL NEEDS THAT WOULD SUPPORT OUR CONTACT WITH THEM?

Head of Year: *

Parents/Carer name: *

Email*

Phone Number*

As the person with parental responsibility, I consent to my child being referred to the Public Health Nursing Service

Parental responsibility Yes No

Signed (Parent/Carer)

or

I am the student and aged over 14, I give I consent for this referral to be sent to the School Nursing Team

Signed

REASON FOR REFERRAL: All referrals must be shared with the parent and/or student prior to being sent to the School Health Team. Referrals will not be accepted without informed consent being given.

WHAT ARE THE EXPECTED OUTCOMES OF THIS REFERRAL?

Name

Signed

Contact Number

Email