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0-19 Referral Form


Please select from the following before proceeding




















Section 1 - Referrer's Information


Section 2 - Key information about the Patient


Please Note: We only accept referrals for under 18 years of age


Section 3 - Reason for Referral





Referral Reason Priority Referral Reason
*1st Reason


Section 4 - Consent


Section 5 - Information about the Child/Young Person


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?

Section 6 - Professionals involved


Agency Name & Role Telephone Number

Section 7 - Referral Information


  • 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?

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