Community Health Services
Specialist Children's Services
Referral Form
(See service description overleaf)
Return form to: Referral Team – Specialist Children's Services,
Guy's and St Thomas' Community Health Services, Sunshine House, 27 Peckham Road,
London SE5 8UH
Tel: 020 3049 8029 Fax: 020 3049 8153
Child’s first name: ---------------------------------------------------Family name ------------------------------------------------ M/F
Parent’s names----------------------------------------------------------------------------------------NHS Number-------------------------Date of Birth:-------------------------------------------Telephone: ---------------------------------------------------------------------------Address: -------------------------------------------------------------------------------------------------------------------------------------------Post Code: --------------------------School/Nursery: ---------------------------------------------------------------------------------------GP: ---------------------------------------GP address:------------------------------------------------------------------------------------------HV/Sch Nr: ----------------------------------------------- HV/SN Base-----------------------------------------------------------------------Please indicate which services you would like the child to be referred to:
□ ( see attached notes for eligibility form home visiting service)
Community Paediatricians □ Special Needs Health Visitor for Continence Assessment □
Occupational Therapy □ Community Children’s Nurses □
Speech & Language Therapy
Is an interpreter needed for the assessment?
Yes/No
Does the child have a hearing impairment? Yes/No
□
Physiotherapy
If yes, in which Language-------------------
Date of recent hearing assessment--------------------
Is the child aged under 4.6 years with younger siblings? Yes/No
If applicable, indicate stage on Code of Practice: School Action, School Action Plus, EY action, EY action plus,
Statemented (please attach latest IEP/psychologist report).
□
□
□
□
□
Other agencies involved: Audiology
ENT
Social Service
SEN
Other
(please give details)
(Please indicate if you have referred the child to any of these services)
Reason for referral: (Relevant background information e.g. known special needs, child protection, Looked After,
family history, birth history, medical history, history of poor attendance etc. Please attach relevant reports). Please
give details of what parent/carer and child are expecting from referral.
(Please continue on separate sheet if necessary)
Consent:
Has informed consent been obtained for the child to be referred?
Yes/No
Date: ------------------------------
Name of Referrer---------------------------------------------------------------------- Date of referral:
Designation--------------------------------------------------------------------Tel no.---------------------------------------------------------Contact Address: ------------------------------------------------------------------------------------------------------------------------------Designation--------------------------------------------------------------------Tel no.---------------------------------------------------------Contact Address: -------------------------------------------------------------------------------------------------------------------------------
Version July 2011
Specialist Children’s Services
We offer services and resources for children and young people up to 18 years of age living in Southwark with a
variety of needs such as vulnerable children and children with developmental difficulties, disabilities or chronic
health needs. We are a multi-professional team working together with other agencies to offer advice, assessment
and treatment for children and families. We work within the framework of the National and London child protection
procedures.
How can a child be referred?
We accept referrals from a variety of services including GPs, Health Visitors, Hospitals, schools, Social Services
and other professionals. Your child may need services from one or more professionals. We work closely together to
share information and plan joint assessment and intervention to best meet your child’s and your needs.
Administration Team
We are the first point of contact for patients, parents, GPs and Community Professionals. The Administration Team
organises and sends out appointment letters for your child to be seen at the Sunshine House, at the local health
centre, school or in the home.
Speech and Language Therapists (SALTS)
We often see children when parents, carers or teachers are worried about a child’s communication: speaking,
listening, understanding and interacting. We also see children with swallowing and eating difficulties. We begin by
working with parents, carers and school/ early years staff to understand the child’s strengths and needs and with
them put together a plan to support the child, family and school. We mainly work in clinics, schools, early years
settings or at home.
Sure Start Children’s Centres home visits will be automatically offered to:
 Children aged 2 ½ years or under
 Children under 4.6 years with younger siblings
Also, the referrer can request home visiting input. To request this, the referrer should contact department via
administrator – through e-mail or telephone call.
Community Paediatricians
We are doctors who specialise in children's health, development and care needs. We are involved in assessing the
child as a whole, the child's diagnosis, planning and co-ordinating care, liaising with other professionals and offering
advice and support to the family.
Special Needs Health Visitors and Special Needs School Nurse
We offer a number of services including: providing information on national support networks, discussing
appropriate pre-school provision, carrying out continence assessments for the provision of nappies/pads (from
three years), providing information on local resources and support groups, discussing general disability issues,
helping with disability benefits and just listening, if you need it. We work closely with your Health Visitor or School
Nurse in home, school or other environments.
Physiotherapists (Physios)
We help children with their movement skills and physical mobility. We also assess for specialised equipment such
as walking aids. We work closely with the child's family and carers, and see children in many different
environments (eg: at the Sunshine House, at home and at school).
Occupational Therapists (OTs)
We help children to become as independent as possible in daily life. E.g: feeding, dressing, playing. We also help
children develop school skills such as handwriting. We work closely with the child's family and carers, and see
children in many different environments (eg: at the Sunshine House, at home and at school).
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