Dublin South School Age Team Referral Form
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Dublin South School Age Team Referral Form (Only complete this form if you live in the areas; Booterstown, Blackrock, Stillorgan, Monkstown, Dun Laoghaire, Dalkey, Killiney, Ballybrack, Shankill, Foxrock, Carrickmines, Cabinteely) Please complete all sections of this Referral Form. Incomplete referrals will be returned to the referral agent. Section 1: Personal Information and Consent Child’s Name: Date of Birth: Address: School and class: Parent(s) Names: Parent(s) contact numbers: Parent(s) address (if different from above): Parent(s) email address(es): Referral Agent and Contact Details: Referral Agent Signature: To be completed by parent(s)/guardian(s): Yes No I/We give permission for my/our child to be referred to the School Age Team I/We give permission that in the event that this referral is not appropriate that it may be shared with other relevant services to facilitate an onward referral. I/We give permission for sharing information (including reports) between relevant professionals. I/We understand that, under current child protection legislation, the HSE SAT has an obligation to share with the relevant authorities any information/disclosure which indicates that your child is at risk of abuse or neglect. Signed_____________________________________ Signed_____________________________________ Parent/Guardian Parent/Guardian Date:______________________________________ Date:______________________________________ School Age Team, Unit 10/11, Leopardstown Shopping Centre, Off Ballyogan Road, Leopardstown, Dublin 18 (01) 921 2533 Current or previous services (Tick: ) Social Worker Area Medical Officer Child Psychiatry Psychologist Public Health Nurse Paediatrician Speech & Language Occupational Therapy Other Therapy Does your child have an existing diagnosis? (if so, please give details)__________________________________________ Is your child aware of their diagnosis (if any)______________________________________________________________ Please give the date of diagnosis and details of diagnostic clinicians____________________________________________ Reason for Referral: _ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ __________________________________________________________________________________________________ Parents Main Concerns: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Child’s Strengths and Interests: _ __________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Section 2: Birth and Developmental History Length of pregnancy (weeks): Birth weight: Delivery (eg C-section/ventouse): Any post-natal complications for mother or child? At what age did your child: Sit: Crawl: Walk alone: Gurgle/babble: Say single words (other than mum and Say simple sentences (2/3 words): dad): Toilet trained (day): Toilet trained (night): Section 3: Family History Who lives in the family home: If your child is adopted or fostered please provide further information (e.g. dates/country of origin etc) School Age Team, Unit 10/11, Leopardstown Shopping Centre, Off Ballyogan Road, Leopardstown, Dublin 18 (01) 921 2533 Has your child suffered any stresses or traumas in the past (bereavement, accidents, family breakup etc)? Language(s) spoken at home? Name of Siblings Age Details of any health services attended or relevant diagnosis Section 4: Present Health and Current Skills Please describe any concerns regarding your child’s: health hearing or vision self-care skills (dressing, toileting, personal hygiene etc) gross motor skills (running, cycling, balance etc) fine motor skills (hand writing, scissors / cutlery) sensory difficulties (seeking or avoiding noise/smell/light/touch/movement) concentration or attention social communication and interaction relationships with peers behaviour and emotional regulation communication skills learning/academic skills changes to their routine Describe your child’s ability to: Take turns: Share: Imaginative/Pretend play: Have a two way conversation: Use appropriate eye contact: Greet others by saying “hi” or “hello”: School Age Team, Unit 10/11, Leopardstown Shopping Centre, Off Ballyogan Road, Leopardstown, Dublin 18 (01) 921 2533 Section 5: Teacher Questionnaire (Please include relevant documents and reports. Teacher questionnaire must be returned with original referral) Name of child D.O.B. Name of teacher Class School (name & address) School Tel No. School email Duration teaching child Number in class Teacher Signature Date completed Please describe students attendance and punctuality Is this student on a shortened school day What are the child’s strengths?_____________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ What, if any, are your main concerns regarding this child? _______________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ What level of support does this child receive in school (resource teaching, SNA access, differentiated curriculum etc)?___________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Has this child been referred to NEPS or had formal assessment? If so, please give details:_________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Please give details on the following skills: Concentration and attention Memory Following instructions Attainment (reading and numeracy) Social skills Behaviour and emotional regulation Fine and gross motor Sensory regulation What are the child’s most recent STEN/standardised educational assessment results? _________________________ _______________________________________________________________________________________________ School Age Team, Unit 10/11, Leopardstown Shopping Centre, Off Ballyogan Road, Leopardstown, Dublin 18 (01) 921 2533 .