Home

0-19 Referral Form

Please select from the following before proceeding

Start new referral
Retrieve previous referral progress

Email Address

Reference Number

Verification Code (Please enter the code emailed to you)

Please complete this form, as fully as possible, with relevant information and details to support the referral.

Section 1 - Referrer's Information

* Legal first name

*Legal surname

*E-Mail Address

*Job Title/Role

*Agency/Organisation

*First line of address

*Town

*Postcode

*Contact Number

*Is this referral for yourself?

Section 2 - Key information about the Patient

* Legal first name of child/young person

*Legal surname of child/young person

Middle name(s) of child/young person

Other name(s) child is known by

*Gender

*Date of Birth

Ethnicity

GP Name

GP Surgery

*Do you consider this referral is high priority?

Please Note: We only accept referrals for under 19 years of age

NHS No (if known), must be 10 digits

Section 3 - Reason for Referral

Please indicate the referral reason you think best aligns to support the needs of the child/young person.
For all Infant Feeding referrals and referrals to Specialist Children's Services please refer to The Children's and Young People's Referral Management Centre: Referral Management Centre | NHFT

Referral Reason Priority	Referral Reason
*1st Reason

Section 4 - Consent

Consent must be sought to share personal information with Northamptonshire Healthcare NHS Foundation Trust and other organisations that can offer support relevant to this referral

*Does the parent/guardian consent to this referral?

If no has the child consented to this referral?

*Is the child Gillick Competent? i

*Can information about the referral be shared with the Parent?

If No please explain why this information is not to be shared with the parent

Section 5 - Information about the Child/Young Person

*First Name of Main Carer

*Last Name of Main Carer

*Main carer's home address and postcode

Preferred email address of main carer

*Relationship of main carer to Child/Young Person

Consent to receive text messages - please ensure mobile contact is provided above

*Who has parental responsibility for the child/young person? (please include full name, relationship to child and an address if different to the child/young person)

*Preferred contact number of main carer

*Is the parent/carer of the child a military veteran?

*Child/young person's current house number/House name

*Child/young person's current street name

*Child/young person's current town

*Child/young person's current postcode

Preferred contact number for the young person if over 16 years

*Education Setting

School / Education Address

Child/Young Persons preferred first language

Child/Young Persons Ethnic Origin

Child/Young Persons Religion

Supporting Information

	Yes	No	Unknown
*Is an interpreter required?
*Is a signer required?
Is the child/young person a Looked After Child or Adopted?
Does the child/young person have an Education Heath and Care (EHC) Plan?
Does the child/young person have a disability?
Are there any safeguarding concerns?
If there is a safeguarding concern is the child/young person currently the subject of a Child Protection or Child in Need plan?

Please specificy what sign language or translation support Child/Young person require

EHA Reference Number:

Section 6 - Professionals involved

Which other professionals are currently Involved?

Agency	Name & Role	Telephone Number

Section 7 - Referral Information

*Strategies already attempted

Other Strategies attempted

*Other professionals/services working with the family

*Other referrals made to specialist service

Voice of the child/understanding of the child

*Detailed reason for referral / history

*Preferred outcome of the referral

For all Growth and Measurement Screening Referrals please advise the following (If the details are not provided the referral may not be accepted):

Why are you working with the child? Please detail intervention and plan.
Why do the 0-19 Team need to monitor, rather than a Practice Nurse/GP/Parent?
Frequency of screening and please specify an end date of screening. Please note that a further referral is required if this needs to be extended.
What needs to happen with the results of each screening? Who needs to be informed and how?

*Please provide answer for the above questions (Please put N/A if your referral is in relation to any other referral reason)

Attachments

Upload supporting information

Please upload any other information relevant for this referral. Please note we accept a maximum of 5 documents, with a maximum 5MB per document, please limit to 5MB per document.

Document Name	Upload Docs

NHFT Referral Forms

Thank you for submitting a referral. Your response has been recorded.