CHILDREN’S LEARNING DISABILITY NURSING TEAM REFERRAL FORM
(INADEQUATELY COMPLETED FORMS WILL BE RETURNED TO THE REFERRER) 

Referral date Required
Invalid date

Patient / Young person's details

Required
Date of birth Required
Invalid date
Required
Is the child/young person known by any other surname? Required
Required
Required
Usual address Required
Required
Tick if the appointment needs to be made by telephone (e.g. for literacy reasons)
Required
Required
Required
Required
Does the child / young person have a learning disability? Required
Does the child / young person have a diagnosis of Autism and is under 11? Required
Identified Physical Health Problem? Required
Has the child / young person been referred previously to the Children’s Health Services? Required
Has an Early Help form been initiated? Required
Does the child / young person have an Education, Health and Care Plan? Required
Are there any safeguarding issues? Required
Does the child / young person have an open referral with CAMHS? Required
Interpreter required? Required
British Sign Language required? Required

Parent/Carer details

Full Name(s) of Parent(s) / Guardian(s):

Required
Required
Required
Required
Required
Required
Required
Required
Permission to leave a message? Required
Do any of the parents / carers have learning difficulties? Required
Has the child/young person given consent for the referral? Required
Has the parent given consent for the referral? Required
Has the parent given consent for the service to access child’s record to gain information about diagnosis appropriate to the referral? Required

Referrer details

Required
Required
Address Required
Required
Signature Required
Has the Child/Young Person been seen by you as a Referrer? Required

Reasons for request

Please continue in additional information section below, if necessary:

Include Diagnosis (if applicable)
 

Required
Required
Required
Required

Identified risk

Please inform us of any known risks in relation to the child/young person being a risk to themselves or others; any risk to child/young person from others (e.g. sexual exploitation, sexual abuse, physical abuse) or any risk that may potentially occur to staff whilst working with this child/young person or family.

Required
Required

Children’s Learning Disability & Behaviour Support Service
Unit 23 
Lillyhall Business Centre
Jubilee Road
Workington
CA14 4HA
01900 705081