Please Return This Form, Along with Any Relevant Additional Information, To

Please Note: Fields marked ‘*’ are mandatory. Any SPA forms returned with one or more of these fields incomplete will be automatically rejected and returned to the referrer.

*Forename of child : *Surname of child : *Referrer name : Designation : *D.O.B. NHS No *Gender *Address :

*Address : Postcode *Tel No. : *Parent’s / carers names : * H * M W

*Who has parental responsibility for child?

As Above Other (if ‘Other’, please provide details)) How long have the family lived in the UK? Home Languages (including English) Written Spoken Writte n Please cross if interpreter is needed *Principal Reason for Referral :

Other information to support reason for referral; In order to process this referral appropriately please specify the following:

 Nature of Concern :

 How long these problems have been evident :

 If the child is experiencing functional / developmental / behavioural difficulties please state the child’s current abilities and difficulties (eg, how do these difficulties affect the child at school/nursery/home) :

I consent to the above referral and any assessment that may be required. I consent to information being shared with the appropriate statutory agencies as long as it is in the best interest of my child Name and signature of Parent / Carer

*Verbal consent obtained from parent by referrer? Yes No For help completing this referral please refer to the SPA guidelines available from http://website.leicschildhealth.nhs.uk/_Resources-ReferralCriteria.aspx, or alternatively contact the Children’s Disability Service Helpline, Monday-Friday 12-2pm on 0116 225 6560

Have any diagnoses already been made? Please detail by whom and when:

List courses of action tried to date and please state by whom?

*Are any other services currently involved? Yes No Please provide contact telephone numbers where possible

Which school does the child attend?

Does the child have Special Educational Needs? Yes No Please cross as appropriate Action Spoken Written

Are any of the following in place for the child (if so please provide copies):

Common Yes No Assessment Framework (CAF)

Child in Yes No Needs Child Yes No Protection Is the child a Yes No Looked after

If so please provide details of social worker in the space allocated above Views of child / parent or carer :

*Signature Date of referral : of profession al completin g referral : Tuesday, 14 May 2013 Please return this form, along with any relevant additional information, to: Single Point of Access, Leicester, Leicestershire & Rutland, Children’s Community Health Service Bridge Park Plaza, Bridge Park Road, Thurmaston, Leicester, LE4 8PQ Tel: 0116 225 2525 Fax: 0116 2958302