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Thursday 19 October 2017
Derbyshire Healthcare NHS Foundation Trust
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Specialist and Children's Services

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Single Point of Access - multi agency referral form (emotional & behavioural problems)


Is an interpreter needed? »
Is the child excluded from school or at risk of being permanently excluded or doesn't attend school for any other reason?  »

Reason for referral:

In order to process this referral appropriately it would be a great help if you could specify the nature of the concern: 


Please indicate significant problems & needs by underlining or highlighting any of the following: 


Low mood; hearing voices; anxiety/phobias; deliberate self-harm; suicidal thoughts/threats; other emotional difficulties; eating/weight difficulties; behavioural problems; social & communication difficulties; hyperactivity; stress; poor concentration; post trauma symptoms; abuse; family breakdown; bereavement; attachment needs; peer bullying; physical/ learning disability; learning needs; parental mental health needs.; obsession and/ or compulsions with inherent fear;  vocal or motor tics.

Any known allergies? »
Have you completed an Early Help Assessment (EHA)? »

Have you arranged a Multi-Agency Meeting? »
Is the child known to have a statement/EHCP/GRIP? »
Looked After Child? »
Child On A Protection Plan? »
Children In Need?  »
Is the child privately fostered? »
Is the child adopted? »
Is the child involved in any court proceedings? »

Who has parental responsibility for the child/young person?

Is the family known to any of the following? If so, please tick and give names & telephone numbers:

Details of services and professionals involved:

Further information/reports attached to this referral: »


Consent discussed with child/family and agreed for referral
Consent agreed to share and gather information between services