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