School Health Service (East Sussex) referral form

Your information

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For your security, this form will time out after 30 minutes. Please make sure you have any information necessary beforehand.

If the child for whom you are seeking support has not previously accessed this service for any of the following - bowel and bladder (toileting), oral health or sleep - please see our Universal resources page - as this is a required part of early intervention access and support.

"*" indicates required fields

Are you a ...*

Are you making a...*

Young person referral

Consent

School

Secondary school / college*

If not in education please select 'Not in education' from the dropdown list.

Year group*

Reason for referral

Reason for referral*

Your details

Your first name*

Your surname*

Are you know by any other name or have previously

Your date of birth*

Your gender*

Female

Male

Other

Is this the same as your sex at birth*

Yes

Your pronouns*

Other, please specify*

Your sexual orientation*

Other, please specify*

Your ethnicity*

Other, please specify*

Your religion*

Other, please specify*

Your address*

Address line 1 Address line 2 Town County Postcode

Your phone*

Your email*

Are you happy for us to contact your parent/carer about your referral?*

Yes

Parent/carer details

Name*

First Last

Their relationship to you*

Do they live at the same address as you?*

Yes

Their address*

Address line 1 Address line 2 Town County Postcode

Their phone*

Their email*

Communication details

To support our ambition to provide sustainable care, we will contact patients either by phone, email or text message. If you prefer to be contacted in another way, please contact the service to update your communication preferences.

For more information:

Please note: Personal email accounts are not encrypted, therefore there’s a very small risk that emails sent between us could be opened and read by someone else or ‘hacked’. If you are worried about this we can support you to make your email communications with us extra secure. Please call 0300 123 4062 option.

Do you need any communication support?*

Yes

Please detail communication support*

Questions about you

Are you a young carer?*

A young carer is someone under 18 who has caring responsibilities for another person who is ill, disabled, has a mental health condition or drug and alcohol problems.

Yes

Do you have any special educational needs or disabilities?*

Yes

Please give us details*

Do you have an Education, Health Care Plan (EHCP)?*

Yes

Are there any reasonable adjustments you need to support you to access healthcare?*

For example, appointments on ground floor due to mobility, quiet waiting space.

Yes

Please give us details*

Do you require an interpreter?*

Yes

What language do you require?*

Are you a looked after child (LAC) / child in care (CIC)?*

Yes

Is your social worker aware of this referral?*

Yes

Do you have any social, cultural or religious beliefs that may be impacted by us providing healthcare?*

For example, not usually applicable to our kind of care however, people with certain faiths could need appointments outside of specific times or having a chaperone.

Yes

Please specify*

Is anyone in your immediate family a current or previous serving member of the British Armed Forces?*

Yes

Are you currently receiving help/support or on the waiting list for any other services / professionals?*

For example, social worker, keyworker, paediatrician, counselling, Child and Adolescent Mental Health Services CAHMS.

Yes

who are you being seen by or waiting to be seen by?*

Reason for referral details

What are you worried or concerned about?*

Please give as much detail as possible.

How long has this been worrying you?*

What supportive measures have you tried or are in place?*

Do you have a professional diagnosis for a mental health condition?*

Yes

Are you self-harming?*

Yes

Have you received previous counselling / therapeutic interventions?*

Yes

What would you like to achieve as a result of this referral?*

After submitting a referral to the East Sussex School Health Service.

Your referral will be triaged by our Specialist Community Public Health Nurses/Mental Health Practitioners at our daily triage meeting. The purpose of the triage meeting is to consider all the available information and decide if East Sussex School Health are the most suitable service or whether there may be other appropriate services that can be recommended.

If the information in the referral identifies that the referral meets our criteria a member of our admin team will either contact you or if requested your young person or the young persons school to book an assessment. Please note that calls may come from a ‘withheld number’. We aim to make contact within five working days.

If the information in the referral identifies that the referral does not meet our criteria we will be unable to offer an assessment but will provide some signposting to other services / resources.

Parent/carer referral

Please only complete this referral if you are the parent/carer of the child/young person and have legal responsibility for them. If not, please select 'Professional'.

Consent

For parent/carer.

Is the child or young person...*

Primary school aged (4-11 years old)

Secondary school aged (11-13 years old)

Secondary school/college aged (13+ years old)

I have discussed this referral with my child / young person and consent to being contacted*

Yes

No, please say why*

Referral consent

For professionals.

You will need to show the legal basis for referring this parent / carer / young person (KCHFT will not process your referral unless you indicate which applies below):

Article 6 (1) of the General Data Protection Regulation:*

(a) Consent of the parent / carer / young person

(b) Performance of a contract with the parent / carer / young person

(d) Vital interests (life or death) of the parent / carer / young person

(e) Performance of a task carried out in the public interest or in the exercise of official authority vested in the data controller

(f) Processing is necessary for the purposes of the legitimate interest pursued by the data controller

Is the child or young person...*

Primary school aged (4-11 years old)

Secondary school aged (11-13 years old)

Secondary school/college aged (13+ years old)

School

Primary school*

If not in education please select 'Not in education' from the dropdown list.

Secondary school*

If not in education please select 'Not in education' from the dropdown list.

Year group*

Reason for referral

Reason for referral (primary school aged)*

Reason for referral (secondary school/college aged)*

Child/young person details

First name*

Please provide first name as registered on birth certificate unless legally changed

Surname*

Please provide last name as registered on birth certificate unless legally changed.

Is your child known by any other name or have a previous name?

Date of birth*

Their gender identify*

Female

Male

Is this the same as their sex assigned at birth?*

Yes

Their pronouns*

He/him

She/her

They/them

Other

Other, please specify*

If child/young person is age 13+, how would they describe their sexual orientation?

Other, please specify*

Their ethnicity*

Their religion*

Child/young person address*

Street Address Address Line 2 Town County Postcode

NHS number

Child/young person GP address*

Address Address line 2 City County Postcode

GP phone number*

Young person consent

Young person consent obtained?*

Please confirm the young person is aware of and in agreement with this referral, without this we will not be able to support you with your concerns.

Yes

Young person phone*

Young person email*

Has the young person consented to their parents/carers being informed of the referral?*

Yes

Why has the young person not given consent?*

Parent / carer details

Parents name*

First name Surname

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OLD INACTIVE Their relationship to the child/young person

Their relationship to the child/young person*

Is the address the same as the child / young persons?*

Yes

Address*

Address Address line 2 City County Postcode

Phone*

Email*

Parental responsibility

Does the parent/carer have parental responsibility for the child/young person?*

Yes

Name of person with parental responsibility*

First name Surname

Relationship to the child/young person*

Contact details*

Communication

For more information:

This field is hidden when viewing the form

OLD Does the young person prefer not to be contacted in any of these ways please click on the relevant box

Email - opt out

Phone - opt out

Text message - opt out

This field is hidden when viewing the form

OLD Does the parent/carer prefer not to be contacted in any of these ways please click on the relevant box

Email - opt out

Phone - opt out

Text message - opt out

Does the child/young person need any communication support?*

Yes

Please detail support needed for the child/young person*

Does the parent/carer have any communication or learning needs?*

Yes

Please detail communication or learning needs*

Does the parent/carer require an interpreter?*

Yes

If yes, what language do you require?*

Other, please specify

Does the parent/carer consent to being contacted to give feedback or to complete a questionnaire?*

Yes

Does the young person consent to being contacted to give feedback or to complete a questionnaire?*

Yes

Questions about the child/young person

These are compulsory and need a tick box to confirm these have been discussed with parent/ carer/ young person.

Is the child / young person a young carer?*

A young carer is someone under 18 who has caring responsibilities for another person who is ill, disabled, has a mental health condition or drug and alcohol problems.

Yes

Does the child / young person have any special educational needs or disabilities?*

Yes

If yes, please indicate which special educational needs or disabilities and whether these have been officially diagnosed*

Does this child/young person have an Education, Health Care Plan (EHCP)?*

Yes

Are there any reasonable adjustments that your child requires to support them accessing healthcare?*

For example, appointments on ground floor due to mobility, quiet waiting space?

Yes

Yes, please specify*

Does the child / young person require an interpreter?*

Yes

If yes, what language?*

Is the child / young person currently a looked after child (LAC) / child in care (CIC)?*

Yes

If yes, is the social worker aware of this referral?*

Yes

Does child/young person or their family have any social, cultural or religious beliefs that may be impacted by us providing healthcare?*

For example, not usually applicable to our kind of care however, people with certain faiths could need appointments outside of specific times or having a chaperone.

Yes

Yes, please specify*

Is anyone in the child or young persons immediate family a current or previous serving member of the British Armed Forces?*

For example, regular, reserve and national service.

Yes

If yes, please specify*

Is the child / young person currently receiving help/support or on the waiting list for any other services / professionals?*

For example, social worker, keyworker, paediatrician, counselling, Child and Adolescent Mental Health Services CAHMS.

Yes

Who are you being seen by or waiting to be seen by?*

Are there any safeguarding concerns?*

Yes

If yes, please specify*

Reason for referral details

What are you worried or concerned about?*

Please give as much detail as possible.

How long has this been worrying you?*

What supportive measures have you tried or are in place?*

What would you like to achieve as a result of this referral?*

What is your child/young persons views on the reason for this referral?*

Referrer details

Name*

First name Surname

Role*

Other role*

Organisation*

Phone*

Email*

This field is hidden when viewing the form

Referral details

After submitting a referral to the East Sussex School Health Service.

Your referral will be triaged by our Specialist Community Public Health Nurses at our daily triage meeting. The purpose of the triage meeting is to consider all the available information and decide if East Sussex School Health are the most suitable service or whether there may be other appropriate services that can be recommended.

If the information in the referral identifies that the referral does not meet our criteria we will be unable to offer an assessment but will provide some signposting to other services / resources.

After submitting a referral to the East Sussex School Health Service.

If the information in the referral identifies that the referral meets our criteria a member of our admin team will either contact the young person or parent/carer or the young persons school to book an assessment. Please note that calls may come from a ‘withheld number’. We aim to make contact within five working days.

If the information in the referral identifies that the referral does not meet our criteria we will be unable to offer an assessment but will provide some signposting to other services / resources.

Health Visiting transition

Name*

Date of birth*

Gender*

Ethnicity*

Other, please specify*

Address*

Address line 1 Address line 2 City County Postcode

Phone*

Parental email address*

School*

GP*

Family 1st language

Name of parent/carer(s)

A referral can not be made without parent/carer (s) knowledge. Please confirm how the parent/carer(s) was informed*

Phone

Visit

As part of a meeting

Referrer name*

Referrer phone*

Referrer email*

Criteria for handover

Please tick all boxes that apply.

Children with long term health conditions requiring an Individual Health Care Plan eg: Diabetic, epileptic, asthmatic, anaphylaxis. Supporting pupils with medical conditions at school - GOV.UK (www.gov.uk) - consider whether children with EHCP (Education Health Care Plan -for learning needs) needs IHCP in addition for health needs

Children who are subject to a current child protection plan-documents to be attached to referral (see list below (NOT looked after children (LAC) or child in need (CHIN)

Where a child, or siblings, are known as young carers.

Family history of FGM

If you have had a conversation with a member of the ESSH about this referral please state who

Summary of health visiting intervention*

Details of other agencies involved including names and contact details.*

For example, social services. Including named practitioner and their email address and phone number. Please write none if no agency involvement.

Children on Child Protection Plan need to have copies of the following documents attached to the referral

Initial case conference report and minutes. Most recent Health Visiting Case Conference report. Any referrals made by Health visiting service and outcomes including SORs.

Drop files here or

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

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Official use

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Outcome of triage

Recommended

Services

Pages

Leaflets

School Health Service (East Sussex) referral form

Your information

Young person referral

Consent

School

Reason for referral

Your details

Parent/carer details

Communication details

Questions about you

Reason for referral details

Parent/carer referral

Consent

Referral consent

School

Reason for referral

Child/young person details

Young person consent

Parent / carer details

Parental responsibility

Communication

Questions about the child/young person

Reason for referral details

Referrer details

Referral details

Health Visiting transition

Official use