Community Paediatrics Form

Community Paediatrics

Medical Assessment referral e-form

The role of community paediatrics is to assess for any underlying medical conditions around this child’s difficulties. It is likely that a child will be discharged post assessment should no medical intervention/follow-up be required

This form is to be used for:

Developmental delay (in 2 or more domains)
Isolated speech and language delay (to be completed only by SALT)
Gross / Fine motor delay with no other delay

NB: Autism assessments should be requested using the Barnsley ASDAT Referral form

Important Information

Self referrals are not accepted – All referrals should be made by a professional/agency who knows this child.
Ideally, an Early Help Assessment (EHA) should be in place or in the process of being completed.
Referrals for anything that are not mentioned above will not be accepted by the department.
Paper referrals will no longer be accepted.
Please consider forwarding a copy of this referral to the 0-19 service for information only

Your name

Job Title

Agency / Organisation

Email Address

Telephone No

How do you know the child?

NHS Number

Childs full name

Childs DOB

Gender

House No and Street

Address line 2 (or area)

Town / City

Postcode

Safeguarding Status

Name of lead professional or Social Worker

EHA Number

Status

School Name

Address

Contact Name (normally SENDCo)

Other professionals involved

GP Practice

Named GP

Address

Health Visitor / School Nurse

Name

Contact Number

Relationship to child

Does this person have parental responsibility?