Hampshire Outreach Into Early Years Referral Form

HAMPSHIRE OUTREACH INTO EARLY YEARS REFERRAL FORM

Please complete ALL areas

Date of request
Name of child / Male/Female
Date of birth / School entry year
Name of parent/carer / Child’s position in family
Address
Post Code / Home Language
Home telephone number
Mobile
Email address
Name of referrer / Position held
Address (daytime)
Email address
Contact telephone number
Professionals involved (name/contact address)
GP
Health visitor
Paediatrician
Speech and language therapist
Physiotherapist
Occupational therapist
Social worker
Specialist teacher advisor
Others
Early years provision attended
Address of Provision / Contact telephone number of Provision
Name of Supervisor
Name of SENCO / Name of child’s keyperson
Days and number of hours attended, please state am or pm for example Mon: 3 hrs am
Mon: Tues: Wed: Thurs: Fri:
Reason for referral and any diagnosis (Please give as much information as possible, for example areas of developmental delay or behaviour causing concern along with any strategies that have worked well. All Requests MUST include copies of reviewed IEP/ BMP and any other relevant documented evidence including medical reports).
This request has been discussed with …………………………….…………(Area Inclusion Coordinator)
Parent’s views and concerns

Hampshire County Council complies with the Data Protection Act 1998. By registering these details I understand that the information will be held securely on Hampshire County Council’s databases for the purpose of recording the support provided to your child and family. I give consent to share information with children’s centres, professionals and agencies as appropriate.

Signature of parent ……………………………………… Date …………………………..………….

Signature of referrer…………………………………….. Date……………………………………….

Please return the form to ‘The Inclusion Team Leader’. Include any additional information or reports to support this request. If not completed in full this request will be returned which will cause delay. If there are any areas of concern that the outreach worker should be aware of please contact the service to discuss.

Eastleigh & Winchester
Inclusion Team Leader
SfYC, The Aviary Children’s Centre, Blackbird Road, Eastleigh, SO50 9JW
Tel: 02380 651983 / Havant
Inclusion Team Leader
SfYC, Mill Hill Children's Centre, Mill Road, Waterlooville
PO7 7DB
Tel: 02392 261057 / New Forest
Inclusion Team Leader
SfYC, Winsor Road, Bartley, Southampton SO40 2HR
Tel: 02380 667360 / Test Valley
Inclusion Team Leader
SfYC, The Wedge
London Road,
Andover
SP10 2PS
Tel: 01264 368656
Basingstoke and Deane
Inclusion Team Leader
SfYC, Dame Mary Fagan House, Chineham Court
Lutyens Close
Basingstoke RG21 3ET
Tel: 01256 359002 / East Hants
Inclusion Team Leader
SfYC, Bushy Leaze Children and Families Centre, Eastbrooke Road, Alton, GU34 2DR
Tel. 01420 80862 / Hart and Rushmoor
Inclusion Team Leader
SfYC, 2nd Floor
Rushmoor Borough Council Offices
Farnborough Rd
Farnborough GU14 7JU Tel: 01252 814770 / Fareham and Gosport
Inclusion Team Leader
SfYC, Woodcot Primary School, Tukes Avenue, Gosport,
PO13 0SG
Tel: 01329 286750

Revised July 2014

2014 outreach referral form