Parent/Carer Sensory Group Referral Form :: Derbyshire Healthcare NHS Foundation Trust

Important

Please refer to referral criteria before making a referral.

Has the child/young person you are referring been seen by our service within the last 12 months? Required

None

Yes

Has this referral been discussed with parents? Required

None

Yes

Parental consent for information gathering from any professional detailed on this form is required in order to process this referral.

Parent name Required

Date Required

Section A. Child's Details

Child's Name Required

Date of Birth Required

NHS No Required

Gender Required

Parent's/Carer's Name(s) Required

School

Address (include post code) Required

Home Tel. No

Mobile No

Does the child have a diagnosis of Autism? Required

None

Yes

Is the child/young person a Looked After Child? Required

None

Yes

Information is delivered to the parents/carers lecture style. Please indicate if the parent/carer can access this Required

None

Yes

Preferred Language Required

Interpreter required? Required

None

Yes

Ethnic Origin Required

Section B. Referrer Details (We only accept referrals from the following sources)

Referrals are taken for triage from the following list (please tick as appropriate) Required

GP / Paediatrician / Community Paediatrician

Occupational Therapy / Physiotherapy / Speech & Language Therapist, Social Care Therapists

Specialist Nurses / Health Visitors

Early Years Intervention Team / STePs / SSSEN / Pre-school support

Clinical and Educational Psychologist

Referrer Name Required

Job Title/Position Required

Dept/Organisation Required

Date of Referral Required

Referrer Address Required

Tel No

Mobile No

Section C. GP and Consultant Details (If appropriate)

GP Name

Address

Tel No

Consultant Name

Address

Tel No

Section D. Other Relevant Information

Are there other professionals involved with the child/young person?

Name

Profession

Address

Tel No

Have any other referrals been made and why?

Section E. Reason for Referral

Please describe the sensory difficulties seen and how they affect day to day function/activities (please be specific – what tasks are difficult, what did you observe?) Required

What is the main reason for the referral to the parent sensory group?

How have these issues been addressed in school?

How have these issues been addressed at home?

Referrals received will be triaged and a decision made whether or not the referral meets our service specification criteria.

Acknowledgement regarding referral acceptance will be sent to the referrer, and patient/carer. If the referral is not accepted, it is the referrer’s responsibility to liaise with parents/carers.

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