EARLY INTERVENTION SERVICE
REFERRAL FORM

PLEASE ATTACH RELEVANT REPORTS WITH THIS REFERRAL

(This will greatly speed up the referral process)

PLEASE FILL OUT THIS FORM NOTING THAT NOT ALL SECTIONS WILL BE RELEVANT TO YOUR CHILD

DATE: ______

PERSONAL DETAILS:
Child’s Name: ______Date of Birth: ______
Address: ______PPS Number: ______Country of birth: ______
Public Health Nurse(PHN): ______Phone No.: ______G.P.: ______Phone No.:______
Child’s Age: Years ______Months ______Gender: F ______M ______
PARENT/GUARDIAN AND FAMILY INFORMATION:
Mother’s Name: ______Father’s Name: ______
Address: ______Address: ______
______
______
Contact Phone No.: ______Contact Phone No.: ______Primary Carers: ______Creche/Preschool/School/: ______Siblings:
Name / Age / Involved in other services / Details
Yes / No
REFERRAL INFORMATION:
What are the main concerns regarding your child’s development:
  1. ______
  1. ______
  1. ______
Please tick

Has a diagnosis been made or a condition identified Yes No
If yes please state diagnosis/condition, when and by whom:
______
______
______
______
Please tick
Are there or have there been other services involved with your child? YES NO
If YES please list:
______
______
______
______
DEVELOPMENTAL HISTORY:
BIRTH HISTORY:
Length of pregnancy: ______Birth weight: ______
Place of birth e.g. hospital/home: ______
Type of delivery e.g. normal or caesarean section______
How long was your child in hospital after birth? ______
MEDICAL HISTORY:
  1. Has your child been in hospital since they were born?______
______
______
  1. Other relevant medical history: e.g. epilepsy, diabetes or heart condition______
______
______
  1. Is your child taking any regular medicines? Please give details:
______
______
Any difficulties with (past or present): Eyesight: e.g. wears glasses______Hearing: e.g. ear infections______Feeding: e.g. special diet______
MOTOR DEVELOPMENT:
Has your child achieved the following and if so at what age?Please tick AGE
Yes No
Rolling from tummy to back ______

Sitting without support ______
Crawling/bottom shuffling ______
Pulling to stand ______

Walking independently ______

Running and jumping ______
Please tick
Do you think that your child has any difficulty with balance/ Yes No
coordination? E.g. falls a lot, bumps into things
Please give details: ______
______
______
Does your child have difficulty in fine motor tasks such as grasping small objects, using their two hands, using a spoon/fork or using a pen/pencil or scissors?
Please tick
Yes No
If YES, please give details: ______
______
______
SPEECH AND LANGUAGE/COMMUNICATION:
Has your child achieved the following and if so at what age?Please tick AGE Yes No
Respond to environmental sounds and voice ______
Respond to or recognise their own name ______
Use gestures and pointing ______
Understand simple commands ______How many words can he/she say? ______Can he/she make short sentences? Yes NoDoes your child use any sign language or communication aid? e.g. Irish sign language, Lámh, PECS. If so, please give details______
______
______
______
ACTIVITIES OF DAILY LIVING
Has your child achieved the following? Please tick
Yes No
Drinks from bottle independently

Uses cup
Spoon feeds
Fork feeds
Dresses independently
Toilet trained:
Please tick

DAY Yes No

NIGHT Yes No
SOCIAL, PERSONAL AND PLAY:
Has your child achieved the following and if so at what age?Please tick
Yes No AGE
Show awareness and interest in others ______
Playing with other children ______

Playing with toys ______
Please give examples
What toy/play does your child engage in? ______
What are your child’s favourite activities? (List)
______
______
Describe any difficulties your child has with concentration or attention?
______
______
Please tick
Does your child have any behavioural/emotional difficulties? Yes No
If yes, please give details: ______
REFERRER’S DETAILS:
This form was completed by:
Please tick
Mother: Yes No

Father: Yes No

Health professional Yes No
Other: (e.g. guardian)______
HEALTH PROFESSIONAL DETAILS:Name and profession: ______Phone Work: ______Mobile No.: ______

Signature: ______Date completed: ______

To be completed by parents:

It is essential that at least one Parent/Guardian agrees to the referral, and at least oneparent/guardian signs this form. Where applicable it is advisable that both parents are aware of the referral.

I / we give permission for my/our child

Name: ______

Address:______

to be referred to the Early Intervention Service Intake Forum.

I/we also give consent to the Intake Forum or designated Early Intervention Services to contact and obtain relevant information from: (please name/list services/health care professional – e.g., Speech and Language Therapy, Psychology, Paediatrician etc.

1.______

2.______

3.______

4.______

5.______

6.______

7.______

8.______

Parent/Guardian’s Signature: ______Date: ______

Parent/Guardian’s Signature: ______Date: ______

In the event that this referral is not appropriate for this service, this referral form may be shared with other relevant services to facilitate an onward referral.

Do you consent to sharing of this referral form with other services in this instance?

Please tick

YESNO
What is the main language spoken in the home? ______

______

Please tick

Do you require an interpreter? YESNO

N.B. Please add any further information/comments that you feel is relevant?

______

To be completed at Early Services Referral Forum meeting

Referral presented for discussion on __/__/__/

Present at referral meeting:______

______

______

______

______

______

Referral was assigned to:

Signed: ______

Please return all referral forms to:Clinical Link,

North Lee Early Intervention Service,

HSE, Disability Services,

1st Floor, Blackpool (Adj. to shopping

Centre), Cork

Contact No: 087 787 2250

1

HSE – South