<p> 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.</p><p>*Forename of child : *Surname of child : *Referrer name : Designation : *D.O.B. NHS No *Gender *Address :</p><p>*Address : Postcode *Tel No. : *Parent’s / carers names : * H * M W</p><p>*Who has parental responsibility for child?</p><p>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 :</p><p>Other information to support reason for referral; In order to process this referral appropriately please specify the following:</p><p> Nature of Concern :</p><p> How long these problems have been evident :</p><p> 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) :</p><p>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</p><p>*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</p><p>Have any diagnoses already been made? Please detail by whom and when:</p><p>List courses of action tried to date and please state by whom?</p><p>*Are any other services currently involved? Yes No Please provide contact telephone numbers where possible</p><p>Which school does the child attend?</p><p>Does the child have Special Educational Needs? Yes No Please cross as appropriate Action Spoken Written</p><p>Are any of the following in place for the child (if so please provide copies):</p><p>Common Yes No Assessment Framework (CAF)</p><p>Child in Yes No Needs Child Yes No Protection Is the child a Yes No Looked after</p><p>If so please provide details of social worker in the space allocated above Views of child / parent or carer :</p><p>*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</p>