Specialist Community Children’s Health Care
REFERRAL FORM
SEE PAGE 3 FOR GUIDELINES ON COMPLETING THE FORM
Return completed form to the address shown for each service on corresponding page,
remembering to enclose Reason for Referral for each service
** IMPORTANT **- Please indicate which service(s) you are referring child to:Speech & Language Therapy.....
Physiotherapy ...........
Community Children’s Nursing & Palliative Care Service
Occupational Therapy
IT IS REQUESTED THAT ALL SECTIONS BE COMPLETED
SECTION A
Surname ........................................................ First Name .........................................................
Date of Birth ............................................................... M/F ....................................................................................
NHS Number ................................................. ...........................................................................
Carer’s Name ................................................. Relationship to child ...........................................
Parental Responsibility : Mother Yes
No
Father Yes
No
Address ......................................................................................................................................
....................................................................... Postcode ............................................................
Daytime Tel.No. ............................................ Mobile Phone No. .............................................
G.P. Name/Practice ...................................... G.P. Code if known ............................................
G.P. Address..............................................................................................................................
School/Nursery/Playgroup .............................................................. am
pm
all day
Home Language ........................................................ Is an Interpreter required Yes
Ethnicity Code:
(Please see over for list of codes)
No
PAGE 1
OFFICE USE ONLY:
STAFF CODE
TEAM CODE
SOR
HOSPITAL? Y / N
CODE:
ETHNICITY
SERVICE DATE
STAMP
DATE INPUTTED
ON FIP/PAS
Specialist Community Children’s Health Care
Diagnosis: (if known)
.....................................................................................................................................................
Are any other professionals involved? Please identify.
.....................................................................................................................................................
Please contact referrer for additional information prior to initial assessment
(Referrer to tick if appropriate)
See Guidelines on completing referral
SECTION B
PERMISSION FOR REFERRAL
Parental permission for referral and sharing of information MUST be obtained. Please obtain
the signature of the parent/carer OR sign yourself to confirm that you have obtained verbal
consent. Unfortunately, any referrals received without a signature will be returned.
As the child’s parent/carer I give permission
for this referral and permission to share
information with other professionals
(including school staff).
As the referrer I have obtained parental/carer
consent for this referral and permission to
share information with other professionals
(including school staff).
Signed:.....................................................
Signed: ....................................................
Referred by: ................................................. ................................ Signed: .....................................
(PLEASE PRINT NAME)
Designation or Relationship to Child ......... …………. ................ .Date: .........................................
Referrer’s Contact Address: ...........................................................................................................
....................................................................... ..Tel: No. ....................................................................
PLEASE RETURN COMPLETED FORM TO ONE (OR MORE) OF THE FOLLOWING SERVICES, ENSURING YOU
HAVE INCLUDED THE REASON FOR REFERRAL INFORMATION RELATING TO EACH SERVICE AND FORWARD
TO THE ADDRESS ON THE CORRESPONDING PAGE:
Paediatric Physiotherapy Service
Children’s Speech and Language Therapy
Community Children’s Nursing & Palliative Care
Paediatric Occupational Therapy
PAGE 2
Specialist Community Children’s Health Care
INFORMATION AND GUIDELINES FOR COMPLETION OF
THIS REFERRAL FORM
Our standard is to see children for an initial assessment within 13 weeks of the referral being
received by each service. However, the Community Children’s Nursing and Palliative Care
Team will respond to your referral as each case requires.
SECTION A
In order that we may offer an efficient and speedy referral to our services, we request
that you complete all sections of the form. This will prevent a delay in seeing the
child.
Home Language
It is important that the child’s home language is completed accurately in order for an
appropriate interpreter to be present at appointments, if needed. The following list may be
helpful in identifying the language, but there may be others.
Arabic
Bangla
Sylheti
Mirpuri
Punjabi
Pushto
Hindkoo
Urdu
Gujrathi
Kutchi
Kokni
Vietnamese
Cantonese
Patois
Creole
Somali
Ethnicity Codes:
Please insert appropriate code on referral form
Code
A
B
C
D
E
F
G
H
J
Ethnicity
White British
White Irish
White Other
Mixed White and Black Caribbean
Mixed White and Black African
Mixed White and Black Asian
Mixed Other Background
Asian/Asian British Indian
Asian/Asian British Pakistani
Code
K
L
M
N
P
R
S
Z
Ethnicity
Asian/Asian British Bangladeshi
Asian/Asian British Other Background
Black/Black British Caribbean
Black/Black British African
Black/Black British Other
Other Ethnic Groups Chinese
Any Other Ethnic Group
Declined
Additional Information from Referrer If you have additional information that is not
represented on this referral form, please indicate, by ticking the box, and you will be
contacted prior to an initial assessment being carried out.
SECTION B - Permission for Referral
We can only accept referrals if permission has been obtained from parent/carer.
Parent/carer signature should be obtained. Alternatively, as the referrer, you can take
responsibility and sign on behalf of the parent/carer to indicate that you have obtained
permission.
We also require confirmation that we can share information relating to the child with
other professionals, including school staff for school aged children.
PAGE 3
Specialist Community Children’s Health Care
CHILDREN’S SPEECH AND LANGUAGE THERAPY
REASON FOR REFERRAL
PLEASE ENCLOSE WITH THE REFERRAL FORM
REASON FOR REFERRAL:
.....................................................................................................................................................
.....................................................................................................................................................
PLEASE IDENTIFY / COMPLETE THE FOLLOWING, IF APPLICABLE
Preferred Health Centre: .............................................................................
If initial contact needs to be in a location other than a Health Centre, please indicate where and
reason why:
...............................................................................................................................................
What additional support is already in place? (e.g. SSS, PSS, TA, Code of Practice/CRISP
profile)
.....................................................................................................................................................
What specific support would you like from Speech and Language Therapy?
.....................................................................................................................................................
.....................................................................................................................................................
Is the child known to Social Care and Health? If so, please give details.
.....................................................................................................................................................
.....................................................................................................................................................
Hearing Test
Date Carried Out: ..........................
Results: ..........................................................................
.....................................................................................................................................................
If this is a FEEDING REFERRAL, please obtain medical consent.
Doctor’s Signature: ............................................... Position: ....................................................
Return with Pages 1 and 2 of Referral Form to:
Children’s Speech and Language Therapy,
Sutton Cottage Hospital, 27a Birmingham Road, Sutton Coldfield, B72 1QH
Specialist Community Children’s Health Care
PAEDIATRIC PHYSIOTHERAPY
REASON FOR REFERRAL
PLEASE ENCLOSE WITH THE REFERRAL FORM
REASON FOR REFERRAL:
.....................................................................................................................................................
.....................................................................................................................................................
What is your expected outcome of physiotherapy?
.....................................................................................................................................................
.....................................................................................................................................................
Medical History (e.g. does child have epilepsy)
.....................................................................................................................................................
.....................................................................................................................................................
All initial appointments will be held at a clinic. Please indicate parental preference.
Birmingham Community Children’s Centre, Bacchus Road ....................................
Maas Road Child and Family Centre, Northfield .....................................................
Park House Child and Family Centre, Sparkhill ......................................................
Small Heath Health Centre .....................................................................................
Saltley Health Centre ..............................................................................................
Church Lane Health Centre, Yardley ......................................................................
Good Hope Hospital, Child Development Centre ....................................................
Wilson Stuart School, Erdington .............................................................................
Musculo-skeletal referrals are accepted for the northern half of the City. Clinics are held at
the centres listed below. Please indicate parental preference:Lansdowne Health Centre, Winson Green ..............................................................
Warren Farm Health Centre, Kingstanding .............................................................
Saltley Health Centre ..............................................................................................
N.B. Musculo-skeletal referrals for children living in the south of the City should be sent
directly to the Physiotherapy Department at Birmingham Children’s Hospital.
Return with Pages 1 and 2 of Referral Form to:
Paediatric Physiotherapy Service, Lansdowne H.C., 34 Lansdowne Street,
Winson Green, B18 7EE
Specialist Community Children’s Health Care
PAEDIATRIC OCCUPATIONAL THERAPY
REASON FOR REFERRAL
PLEASE ENCLOSE WITH THE REFERRAL FORM
REASON FOR REFERRAL:
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
What are you hoping to achieve with Occupational Therapy provision & what functional
difficulties is the child experiencing?
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Listed below are some of the areas in which an Occupational Therapist may be able to
help a child. Please indicate the areas of difficulty you consider the child to be
experiencing in relation to their age/intelligence/peers (these can be circled)
Occupational Tasks
 Self-care, i.e. feeding,
dressing, toileting,
bathing/ showering,
sleeping, mobility/
seating, transfers
 Work , i.e. student/
academic skills,
domestic skills
 Play, i.e. play/ leisure,
social skills, community
access skills
Performance Skills







Fine Motor Skills
Gross Motor Skills
Sensory Skills
Perceptual Skills
Sensory Motor Skills
Cognitive Skills
Language and
Communication
 Skills
 Social/ Emotional Skills
Behaviour




Motivation
Attention
Initiation
Concentration
Specialist Community Children’s Health Care
OCCUPATIONAL THERAPY
Continued
Children referred must fit the following criteria:



Children 0 – 7 years 11 months with functional difficulties
Minor equipment needs for home will be met for children 0 -7 years 11 months
Please note major equipment needs should be referred directly to Social
Services Occupational Therapy Team
An information pack will be provided to older children and their families
Return with Pages 1 and 2 of Referral Form to:
Paediatric Occupational Therapy Service
5th Floor Waterlinks House
Richard Street
Nechells
Birmingham
B7 4AA
Specialist Community Children’s Health Care
COMMUNITY CHILDREN’S NURSING & PALLIATIVE CARE
REASON FOR REFERRAL
PLEASE ENCLOSE WITH THE REFERRAL FORM
REASON FOR REFERRAL:
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Care Required
.....................................................................................................................................................
.....................................................................................................................................................
Medical History (e.g. does child have epilepsy)
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Equipment / Dressings Required
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Continued / ........
Specialist Community Children’s Health Care
COMMUNITY CHILDREN’S NURSING & PALLIATIVE CARE
Continued
Any additional information
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Return with Pages 1 and 2 of Referral Form to one of the following addresses
Please fax urgent referrals to appropriate fax number:Referral of children with South G.P.’s
Community Children’s Nursing, Barbara Hart House, Monyhull Hall Road, Kings Norton, B30 3QJ
Telephone Number: 0121 459 0786 Fax Number: 0121 459 0786
Referral of children with North / East / HOB G.P.’s
Community Children’s Nursing, Bloomsbury Health Centre, 63 Rupert Street, Nechells, B7 5DT
Telephone Number: 0121 465 3614 Fax Number: 0121 359 6732
Referral of children to the Palliative Care Service (Footprints)
Community Children’s Nursing, Castle Vale Health Centre, Tangmere Drive, Castle Vale, B35 7QX
Telephone Number: 0121 465 1577 Fax Number: 0121 465 1573