Child's Name ^*

Include any previous names

Child's Address ^*

Child's Date of Birth ^*

Child's Sex ^*

Male Female

Child's First Language ^*

Interpreter required? ^*

Yes No

Child's Ethnicity ^*

SEN Stage ^*

Parent/Carer Name(s) ^*

Parent/Carer Telephone Number(s) ^*

GP's Name ^*

GP Surgery ^*

Copy of referral must be sent to GP (please tick to confirm)

Reason for referral ^*

Has the child been discussed at the In School Review / LIFT? ^*

Yes No

If Yes, you must attach minutes and any relevant reports

Drop files here or click to upload

If Not discussed at In School Review / LIFT why is the health referral considered more appropriate? ^*

Please enter 'Not applicable' if this does not apply.

What interventions have been tried and what are the outcomes?

Intervention 1

Outcome for intervention 1

Intervention 2

Outcome for intervention 2

Intervention 3

Outcome for intervention 3

Are Early Help Involved? ^*

Yes No

If Yes, please include details

What are the child's academic attainment levels? ^*

Are they making adequate academic progress? ^*

Please comment on their learning needs / approach and attitude to learning ^*

In your view, does the child have any learning difficulties? ^*

Please comment on the child's social and emotional development

Any anxiety or behaviour indicative of anxiety or self-harming behaviour ^*

Relationship with teachers and other adults in the school ^*

(Include factors such as job share, previous schools attended, change of teachers etc.)

Behaviours ^*

(Please comment on behaviours observed in structured and unstructured times)

Strengths and special skills in any area ^*

Any other relevant information? ^*

(e.g. motor skills, play, particular points of stress or anxiety)

Are you aware of any safeguarding issues? ^*

(e.g. domestic violence, alcohol / drug misuse)

What are the parents’ main concerns regarding their child? ^*

Other family information ^*

Any other information or concern not covered ^*

Please attach any supporting documents

Drop files here or click to upload

Involvement with Other Agencies / Services: (Please tick as appropriate)

Educational Psychology

Specialist Teaching & Learning

Social Services

Speech and Language Therapy

I can confirm that the child is known to ALL of the agencies selected above

Parental consent

This can be verbal consent

I can confirm the parent/carer with parental responsibility (as below) has given verbal consent for the child/young person above, to be referred to EKHUFT Community Doctors for an assessment

Community Child Health School Referral Form