Self referral form | Action For Children

Referrer Details

Referrer Name *

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Referrer Job title *

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Referrer Email Address *

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Referrer Address Line 1 *

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Referrer Address Line 2

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Referrer Address Line 3

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Referrer Town/City *

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Referrer Post Code *

Referrer Landline Number

Referrer Mobile Phone Number

Please confirm you have the agreement of the young person/their carer to make this referral *

Yes

No

Please describe what services you have already provided to the child family: *

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Child/Young Person details

First Name of Child *

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Last Name of Child *

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Date of Birth of Child *

Gender of Child *

Is the gender the same as assigned at birth? *

Ethnicity of Child *

NHS Number of Child

Address Line 1 (Child) *

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Address Line 2 (Child)

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Address Line 3 (Child)

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Town/City (Child) *

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County *

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Post Code (Child) *

Consent to contact by post? *

Yes

No

Landline Number (Child)

Consent to contact on this number?

Yes

No

Mobile Phone Number (Child / Parent / Carer) *

Consent to contact on this number? *

Yes

No

Can we send you SMS Text messages and reminders? *

Yes

No

Whose number is this?

Email Address (Child)

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Please indicate their preferred method of contact *

Name of School/College/Nursery *

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Details of any educational healthcare plan: *

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Parent/Carer details

Parent/Carer First Name *

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Parent/Carer Last Name *

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Ethnicity of Parent/Carer

Email Address of Parent/Carer *

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Consent to send Emails to this Email address? *

Yes

No

Who has parental responsibility? *

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Who does the child live with? *

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Parent/Carer address same as childs address?

Address Line 1 of Parent/Carer

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Address Line 2 of Parent/Carer

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Address Line 3 of Parent/Carer

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Town/City of Parent/Carer

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Post Code of Parent/Carer

Any additional needs of parent (e.g. disability/literacy/interpreter etc)

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Any additional needs of child (e.g. disability/literacy/interpreter etc)

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GP Surgery *

Consent to contact GP? *

Yes

No

Any history of eating disorder?

If Yes , please describe presenting issue

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Child/Details of Presenting problem

Please give details about behaviours observed: Mood/Emotions/Communication/Appetite/Sleep *

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How long has this difficulty been present?

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Is this difficulty present in all areas? E.g. at Home, School or Socially

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Social History (Please include details of any relevant family circumstances, life events, bereavements, parental mental health / Learning Disability / Ill Health / Substance Misuse / Domestic Abuse)

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Does the young person have a learning disability? Please give details on level of severity:

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Details of any current medication/dosage:

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Any known risk factors - child and family? (for e.g. violence, substance misuse)

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Additional relevant information:

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Is this referral for a Looked After Child? - Send SDQ if available

If the referral is for a Looked After Child, is the child from Stoke, Staffordshire or out of area? Please state:

Please give details on the communication, social interaction and rigid, repetitive and stereotyped behaviours of the child

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Please describe how you believe this referral will benefit this child and their family and what do you believe would be the most appropriate focus of our work? *

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What would the young person want us to work on with them? *

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Written Consent of Client *

Yes

No

Verbal Consent of Client *

Yes

No

Referral Confirmation *

Yes

No

Written Consent of Person with Parental Responsibility *

Yes

No

Verbal Consent of Person with Parental Responsibility *

Yes

No

Privacy and Consent