Circular 108-10 Bromley Early Support Pre-School Panel Referral Form

REFERRAL FROM HEALTH TO

BROMLEY SPECIALIST EARLY YEARS EDUCATION SERVICES

Referrer to complete form andsend to:Data & Panels Manager, PSS&D Service, Phoenix CRC, 40 Masons Hill,Bromley BR2 9JG,

Tel: 020 8315 4718/ 020 8315 4752Fax: 020 8466 8855E-mail:

1.Child’s details (Please PRINT details in CAPITALS)
Child’s Forename:
(Please print) / Surname:
(Please print) / ONE No:
(Office use)
D.o.B: / Gender:MaleFemale / Siblings:
Address: / Full Names of parents / carers (Mr, Mrs, Miss, Ms):
Full name and contact details of health lead practitioner
Postcode:
Home Tel: / Family’s first language:
Work/Mobile Tel: / Family’s ethnicity:
Email address: / Is help required in interpreting and/or
reading any information?Yes No
2. Referral
Please indicate with a tick in the box(es)your reason(s) for referral to education, and say briefly here what outcome you are expecting forthis child from specialist early years education services.
Initial assessment by the Specialist Early Years Education Services
Initial assessment by Sensory Support (Vision) (Hearing)
Note: If your concern is focused on hearing or vision needs then please do not complete this form until you have telephoned the Bromley Sensory Support Service - 01689 889 850 (Vision) / 01689 889 856 (Hearing)
Complex health needs only - training and support in pre-school and preparation for school transition
Educational Psychology Service
Note: / Parents/professionals can apply directly to Petts Wood SN Playgroup and do not need to be referred through this form
Notes: (Office use only)
PTO Referrer and parent/carer to sign at end
3. Information on current professional involvements with child and action being taken

Agency/Service

/ Name and or professional contact / tel nos
Education (where known)
Pre-school/early years setting
Sensory Support
Care (where known)
Social Worker (Disabled Children’s SW and SB Team)
Social Worker (Other)
Others (where known)
Voluntary Services and others
4.HEALTH MAP – CURRENT SERVICES WORKING WITH THE CHILD
Service / Service lead / Sessions / Health outcomes for next 6 months
Other health referrals already made, e.g. CCDS
NB: Relevant reports supporting the personalised health map must be attached – the Services are unable to accept referrals without this information
e.g. Paediatrician Speech and Language Therapy Occupational Therapy
Physiotherapy Other (please specify)
5.Parents’/Carers’ Consent
Parental signature must be obtained before this referral can be actioned.
(a)Is this child a ‘Looked After Child’? (LAC, e.g. foster care) / Yes No
(b)Is this child subject to a Child Protection Plan? / Yes No
(c)Is this child subject to a Child in Need Plan? / Yes No
(d)Is there a CAF in place? / Yes No
(e)Please add any views or comments and sign to confirm your agreement to the referral and give permission for the Panel to share information confidentially with appropriate education, health and social care professionals in order to support your child.
Parent’s/Carer’s Signature: ………………………………………………………………………….. Date:…………….………
Parent’s/Carer’s NAME (PLEASE PRINT)………………………………………………………………………………………..
Relationship to child (PLEASE PRINT)………………………………………………………………………………………..
The information on pupils with SEN is provided/gathered in accordance with the Data Protection Protocol agreed between Bromley LA and the Admissions Authorities within the Borough. You may receive services from a number of people. So that we can all work together for your child’s benefit, we may need to share some information. We only ever use or pass on information if professionals have a genuine need for it. Law strictly controls the sharing of some types of very sensitive personal information. Anyone who receives information from us is also under a legal duty to keep it confidential. All data are stored on a secure database. Relevant information shared will remain confidential through observance of best practice set out in HM Government’s information sharing guidance (2008) and the Data Protection Act (1998)
6.Referrer’s Details: (PLEASE COMPLETE IN FULL)
Referred by:Position:
Tel No:Email:
Contact Address
Referrer’s Signature: ………………………………………………………………………………….. Date:…………….………
N.B. If there are any specific domestic circumstances that should be made known to Bromley Specialist Early Years Education Services, then please let us know.

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