Ifyou Are a Health Visitor Or Early Years Setting Practitioner

Referral Form – Early Years SEND Service

(Portage/Nigel Hunter Nursery or Outreach Practitioner Support)

Ifyou are a Health Visitor or Early Years Setting practitioner

a My Plan, My Assessment or My Plan+ must be attached

If you are a health professional please ensure that you have you followed the early notification process and check box to confirm this / YES ☐ NO ☐
Is the child on the Social Communication Pathway? / YES ☐ NO ☐
1 / Name of professional/setting referring
Job Title
Address (for correspondence)
Including postcode
Telephone
Email Address
Signature of Parent / Carer
Signature of Referrer
Date of Referral
2 / Please tick which of the following statements relate to the child’s needs – (to be completed from the parent / carer’s point of view)
If you have attached a My Plan, My Assessment or My Plan+ leave this section blank and go straight to Section 3
Reason for referral:
3 / Child’s Details
Name of Child
Date of Birth / male / female
Address where child lives
Including postcode
Telephone number
Mobile number
Email address
Name(s) of parent(s)/carer(s)
Names of siblings with DOB
Ethnicity / Home Language
Name, address and contact details of all EY settings attended (if applicable)
Key worker name and contact details including email and telephone number / Sessions attending:
4 / Attach copy with this referral of:
My Plan
My Plan+
Any other assessment plan the child has now or previously?
Lead Professional/Key Person
5 / Does the child have a Social Worker:
*if the child is in care please seek consent from social worker
6 / Does the child have a diagnosed condition/illness or disability or any other specific conditions?
such as seizure/convulsion, need oxygen at home, heart condition, asthma/allergies, difficulties with vision,hearing or feeding?
Parent(s)/carer(s)
What would you like to tell us about your child?
What support would you like from our Service?
7 / Nature of developmental difficulty (main area)
Please tick relevant box/es / ☐ Cognition and Learning☐ Hearing and Language
☐ Interactive Social ☐ Locomotor
☐ Manipulative ☐ Self Care Social
☐ Speech and Language ☐ Visual
8 / What has already been done to support this child and family,or
if attaching a My Plan, My Assessment or My Plan+: What do you think our Service can offer?
Please give examples of what has been tried already (e.g. My Plan, Early Start Baby group, targeted Stay and Play, community nursery nurse, etc)
9 / Other agencies involved with child: Please include copies of relevant reports/letters to support this referral
No need to complete if an up-to-date My Plan, My Assessment or My Plan+ is attached
Agency / Date Involved / Name of Professional / Contact Details / Letter/Report Attached
Yes/No
Paediatrician
Health Visitor
Speech and Language Therapist
Advisory Teaching Service
Physiotherapist
Educational Psychologist
Family Support Worker
Social Worker
Lead Professional
Other
Other
10 / Have you attached the most recent Development Assessment eg
ASQ / ☐ /
EYFS / ☐ /
Summative Assessment / ☐ /

Please return this form to:

Orpost to:-Early Years SEND Service (New Referral), Gloucestershire County Council, Shire Hall, Block 4, 3rd Floor, Westgate Street, GloucesterGL1 2TG

For office use
Consent form signed / YES ☐ NO ☐
Service information given to parent/carer / YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐

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S:EYSENDPaperwork/Early Years SEND Referral Form Sept 2017