Patient Initials: NHS No: BC Ref:

Children’s Pro-forma & Triage Sheet

Type of Request: / Routine: / Care Package:
Residential / Therapeutic Placement:
Equipment:
Urgent: / Respite:
Transport:
Specialist Assessment /
Recovery Programme:
Full name: / Patient BC Reference(office use)
GP: / NHS No:
Practice: / Health Case Manager:
Practice Code: / Email Address:
CCG: / Phone Number:
SS ID/ Ref Number: / Social Worker:
Email Address:
Telephone:
Date of Birth: / Age:
Present address:
Postcode:
Next of Kin: / Contact number:
Primary
Diagnosis: / Secondary Diagnosis:
Nature of request:
Further information (if applicable)
Request received from*: / Contact Number:
Email:
Date of request*: / One off cost:
Date Package or service to commence: (if applicable) / Cost per week:
Cost per annum / total package:
Area of request: / Children
The CSU will not be able to make an informed decision unless the following appropriate,current and accurate information is supplied with this request:
Fields indicated with an (*) MUST be submitted in conjunction with this application form otherwise it will not be considered. Please indicate below which assessments you have included in support of your application with a (√). Please note that the panel will rely on the evidence submitted to reach their decision.
Health Needs Assessment* / Parental Assessment* / Care/Contingency Plans*
Social Care Assessment* / Providers Assessment* / CAMHS Psychology Report
Home Risk Assessment / Educational Statement / Children’s Decision Sup. Tool
Quotation*
(For equipment/goods requests) / Therapy Reports (Specify)*

CSU Office Use ONLY:

AdminCase Comments:

Name:
Date:

Case Manager Comments:

Name:
Date:

Senior Commissioning Manager Comments:

Name:
Date:

Decision from CSU/CCG:

Approve or Decline
Signature
Date
Details of Panel Decision
(If applicable)
Review period (please circle as appropriate) / 3 months 6 months 9 months 12 months
Other (please specify) :

Decision from LA:

Approve or Decline
Signature
Date
Details of Panel Decision
(If applicable)

Team Action:

Action: / Date: / Initials:
Decision Communicated:
Broadcare:
Patient file linked to Broadcare:
Equipment to be Ordered
Photocopy triage and quote for ordering
ISFE Budget Code:
Requisition Number:
Purchase order number:
Date ordered:

Please ensure that the completed form is returned to us electronically:

Email:

Address: Complex Children’s Team

Individual Patient Activity

NHS Staffordshire and Lancashire Commissioning Support Unit

Lancashire Business Centre

Jubilee House

Centurion Way

Leyland

PR26 6TR

For queries, please contact; Sue Beattie (Children’s Commissioning Support Officer) on

01772 214028 Safe Haven Fax: 01772 227024

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CSU Children's Pro-forma_v.1_131213_EK