Northamptonshire Children & Young People's Services - Referral Management Centre: 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)

Children and Young People's Specialist Community Health Services

(for Northamptonshire Healthcare NHS Foundation Trust & Northampton General Hospital)

& Emotional Wellbeing and Mental Health Services

(for Northamptonshire Healthcare NHS Foundation Trust CAMHS and REACH Collaborative : Youth Counselling)

Please complete the form fully and accurately with correct contact details, relevant information and details to support clinical screening and to prevent any delay in processing. This will ensure the needs of the child or young person are met by the most appropriate service or services.

Section 1 - Referrer Details

Title

*Legal first name

*Legal surname

*E-Mail Address

*Job Title/Role

*Referrer's Organisation

Name of Referring Organisation

*First line of address

*Town

*Postcode

*Contact Number

*Is this referral for yourself?

Section 2 - Key information about the Child/Young Person

* 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

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

NHS No (if known), must be 10 digits

*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

If you are referring the child to MHST, you must specify the name of the child's School.

School (If known)

Child/Young Persons preferred first language

Child/Young Persons Ethnic Origin

Child/Young Persons Religion

Preferred contact number for the young person if over 16 years

Section 3 - Service(s)

Please indicate the service(s) you think are required to support the needs of the child/young person. These services are provided by a range of organisations including Northamptonshire Healthcare NHS Foundation Trust (NHFT) and Northampton General Hospital (NGH). If you require further clarification on the services that are offered by NHFT, please visit www.nhft.nhs.uk/children.

Service Priority	Service Required
*1st Service

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

*Tick this box to confirm that consent has been discussed and received

Section 5 - Information about Parental Responsibility and Main Carer

Parental Responsibility

*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)

*First name of this person

*Last name of this person

*Preferred contact number

*Consent to receive text messages

*Is their address the same as the child’s address?

If No, please specify their address

The main carer is typically the person who takes on the day-to-day responsibility of caring for the child. This includes tasks like feeding, bathing, helping with homework, and managing daily routines. The main carer is often the person the child spends the most time with and who is primarily responsible for their physical and emotional care.

*Is this person the child/young person’s main carer?

If No, please specify their first name, surname, address, email and telephone number

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 Special Educational Need and/ 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?
Does the child/young person require reasonable adjustments to attend appointments?

Main Reasonable Adjustment (if applicable)

List Any Other Reasonable Adjustments

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

Does the child/young person have an Early Help Assessment (EHA)?

EHA reference no. (if known)

Section 6 - Professionals involved

Which other professionals are currently involved?

Agency	Name & Role	Telephone Number

Section 7 - Referral Information

Please note there is a 1600 character limit in the fields

*What is the support need you have identified for the child?

How do you think and how does the child/young person think this is affecting his/her life and life for the family?

Please outline any strategies that have been used to help the child/young person?

Relevant History

If you are referring to the Community Eating Disorders Service (CEDS) or Dietetics, we are unable to accept referrals if the child’s current height/weight fields have not been completed

Current height in meters

Current weight in kg

If referral is for the Bereavement Service, you must specify information about who has passed away and when

If referral is for CTPLD, you must clearly document level of learning need

If referral for Dietetics for child with feeding tube, you must specify type & size of feeding tube in situ, current prescribed feed, amount of prescribed feed, how is feed administered: pump / syringe / bolus set, oral intake and date of discharge / planned discharge

On a scale of 1-5, how does the child feel he/she is coping?

What does the child/young person think needs to change?

What is life like for the family?

Attachments

We are unable to progress referrals to the CYP ASD/ADHD Service without complete School and Parent/Carer packs - For Home Educated Children, Parent/Carer Packs only. Please attach these below. Please note we accept a maximum of 5 documents, with a maximum 5MB per document, please limit to 5MB per document.

Document Type	Document Name	Upload Docs

Thank you for your submission. This referral will be clinically reviewed against acceptance criteria for the service(s) you have requested.

For accepted referrals – Services will contact yourself and/or the child/family in due course to organise initial assessment.

Should your request for services be declined, the RMC will contact you to advise of this outcome and on-going support available.

DATA PROTECTION NOTICE

Data that you provide to the Trust is processed in accordance with the Data Protection Act 2018, please see the Trust Privacy Notice for further information on how data is used:

https://www.nhft.nhs.uk/privacy/