Wiltshire Portage Services – Referral Form Please complete all boxes where possible and use block capitals (please circle where options) Name of Child: Male Female First Language: English /Other please specify: Date of Birth: Names of Parent/Carers Date of Referral: Address with Postcode Siblings – Names & Ages

Armed Forces Family. Yes No Home Tel. No.

Work Tel. No.

Mobile Tel. No.

Email Address:

Diagnosis – please enclose copies of Assessment Reports/CAF Pre- Assessment or CAF.

Reason for Referral

SEND Lead Worker – Name/Address/Telephone

Health Visitor – Name/Address/Telephone

Other Professionals – Consultants, GP, Therapists, Social Workers, – Name/Address/Telephone -

Your Child’s Week Morning Afternoon Monday Tuesday Wednesday Thursday Friday How can Portage Help?

Referrer Name Address & Telephone Number

Professional Signature Date

Parent Agreement Signature Date

Wiltshire Portage Referral Form 2014 Referrals to the Wiltshire Portage Services Promoting Equal Opportunities throughout Wiltshire

This form should be used by all making Portage Referrals. Parents may also refer their own child.

The following criteria should be met:

□The child is as young as possible or of pre-school age, and has at least 12 months before entering school.

□The child has a 50% developmental delay in at least two developmental areas, one of these must be cognition. (3 years of age or under - 30% developmental delay in two areas of development and one of these must be cognition). or □ A known Medical Diagnosis or Syndrome with delay anticipated as above

Additional information required you MUST include:

□ Up to date report enclosed e.g. Paediatric, Health visitor or other Health Professional, indicating level of developmental delay

Or/Both □ CAF Pre- Assessment Form or CAF – indicating level of developmental delay.

Referrals received without the above paperwork will be returned to the referrer. □The referral has been discussed with parents/carers and their signature obtained.

□The child’s parent/carer must agree to be available to meet with the Portage Home Visitor on a regular basis. This will usually be on the same day each week at a mutually agreed time.

Families who move within or into Wiltshire will normally continue to receive Portage. Please return to appropriate Wiltshire Portage Service Office (please tick box)

□For Wiltshire Portage - Chippenham, Calne, Corsham, Malmesbury, Wootton Bassett, Lyneham, Devizes, Aldbourne, Marlborough, Pewsey, Tidworth, Ludgershall, Trowbridge, Melksham, Warminster, Westbury, Bradford on Avon and surrounding villages.

Please return to: Wiltshire Portage, Kings Rise Children’s Centre, Pewsham, Chippenham, Wiltshire SN15 3SY Telephone: 07780 653888

□For South Wiltshire – Salisbury, Wilton, Wylye, Tisbury, Mere, Shrewton, Amesbury, Durrington, Larkhill, Bulford, Winterslow, Alderbury, Whiteparish, Downton, and surrounding villages.

Please return to: Salisbury Portage Service Salisbury District Hospital, Salisbury, Wiltshire SP2 8BJ Telephone: 01722 336262 ex 2495

For Office use only – Tick and date Date: Date: □Acknowledgement letter to referrer □ Portage Offered Yes/No Date: Date: □Letter to Family/placed on waiting list □Assigned Date: Date: □Initial Visit Made □Discharged/Closed

Wiltshire Portage Referral Form 2014