BARNET CHILD DEVELOPMENT SERVICE REFERRAL FORM



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Barnet Child Development Service Referral Form

For referrals to: Speech & Language Therapy, Physiotherapy, Occupational Therapy, Pre-School Teaching Team, Specialist Team (Advisory Teachers), BEAM, Neurodevelopmental Paediatrics, Community Matrons, Continuing Care Team

Please write clearly and in black ink. Attach all relevant reports and observations. Continue on an additional sheet if necessary.

Incomplete referrals cause delay for children.

|CHILD|Child’s First Name |      |

| |Child’s Surname |      |

| |Date of Birth |      |

| |Gender |Male / Female select as appropriate |

| |Parent / Carer name(s) |      |

| |Address |      |

| | |      |

| |Full Postcode |      |

| |Telephone Number/s |      |

| |Ethnicity |      |

| |Language spoken at home |      |

| |Is an interpreter required? | |

| |(indicate country of origin as well | |

| |as language) | |

| |NHS No / Other identifier |      |

| |GP Name + Postcode |      |

| |School / Nursery / Playgroup |      |

| |School year / Stage of code of | |

| |practice | |

| |Common Assessment (CAF) |      |

| |required or commenced? | |

| | | |

|REFER|Referrer’s Name |Dr Lara Shaffer |

|RER | | |

| |Referrer’s Designation |Consultant Paediatrician |

| |Address for Correspondence |Child Health HQ, Edgware Community Hospital, London HA8 0AD |

| |Telephone Number |0208 732 6559 |

| |Email |Lara.shaffer@ |

| |Date of referral |      |

|CONSEN|Please confirm that the parent/carer: | |

|T | | |

| |agrees to this referral | |

| | |tick to confirm |

| |knows that this referral will be discussed by a multi-professional meeting which includes education, | |

| |community nursing and social care colleagues |tick to confirm |

| | | |

| |Are there any known risks to staff ? | |

| | |if ticked, please specify or phone to discuss |

| |Are there any safeguarding issues? | |

| | | |

| | |if ticked, please attach separate documentation |

Continue Overleaf

INTAKE ADMIN ONLY

|Intak|Accepted by (tick service/s) |Not accepted |

|e | | |

|Date | | |

| | |      |

| |Referrer Observations and | |

| |additional Information | |

| | | |

| |Please continue on a separate sheet| |

| |if needed | |

|PROFES| |Professionals already involved |Professionals requested now |

|SIONAL| | | |

|S | | | |

| |Audiology: | | |

| |Child & Adolescent Mental Health Service or | | |

| |Primary Project: | | |

| |Educational Psychology: | | |

| |Eye Clinic: | | |

| |Health Visitor: | | |

| |Occupational Therapy Services: | | |

| |Paediatrician: | |      |

| |Physiotherapy: | |      |

| |Pre-School Teaching Team: | |      |

| |Social Worker: | |      |

| |Specialist Advisory Teacher(s): | |      |

| |Speech/Language Therapy: | | |

| |Hospital(s): | | |

| |Area SENCO: | | |

| |Other: | | |

| | | | |

For urgent medical concerns Telephone 020 8732 6420 to discuss with one of the Paediatricians (for professionals only).

PLEASE SEND THE COMPLETED FORM BY POST TO ONE OF THE SERVICES BELOW THAT YOU ARE SEEKING FOR THIS CHILD

(contact details below)

|OUR |Developmental Paediatrics |Child Health HQ, Edgware Community Hospital, Burnt Oak Broadway , |0207 794 0500 Ext 26457 |

|CONTAC|Audiology |Edgware, HA8 0AD |Audiology Ext 82398 |

|T | | | |

|DETAIL| | | |

|S | | | |

| |Speech & Language Therapy |Children’s Outpatients, Edgware Community Hospital, Burnt Oak |020 8937 7702 |

| | |Broadway, Edgware, HA8 0AD | |

| |Physiotherapy and Occupational Therapy (NHS) |Oak Lane Clinic, Oak Lane, East Finchley, N2 8LT |020 8349 7000 |

| |Community Matrons |Oak Lane Clinic, Oak Lane, East Finchley, N2 8LT |020 8349 7000 |

| |Children & Young People’s Continuing Care Team |Oak Lane Clinic, Oak Lane, East Finchley, N2 8LT |020 8349 7066 / 7077 |

| |Specialist Team |Building 4, North London Business Park, Oakleigh Road South, N11 |020 8359 7624 |

| |(Advisory Teachers for: VI, HI, ASC, Physical/Medical)|1NP | |

| |Children’s Service Occupational Therapy |Building 4, North London Business Park, Oakleigh Road South, N11 |020 8359 2000 |

| |(LB of Barnet) |1NP | |

| |Pre-School Teaching Team |Early Years Centre, Oakleigh Road North, London , N20 0DH |020 8361 2456 ext 1 |

REFERRAL FORM AND GUIDANCE REGARDING REFERRALS CAN BE FOUND ON OUR WEBPAGE:

.uk/child-development-service

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Points to note:

• If this child already has a medical diagnosis, please note this.

• Please ensure you have attached any relevant reports to support this referral.

• If you are confident you know which services are required, please circle overleaf (top of form).

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