Home Page - Single Point of Access

Referrer Details

* Date of Referral:

* Referrer's Name:

* Job title/relationship to the young person:

Agency if professional making the Request for Support:

* Telephone contacts:

* Address:

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* Email:

How did you hear about us?

Parent/Carer Details

* Parent/Carer's Names:

* Relationship to the young person:

* Telephone contacts:

* Address:

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* Email:

* Young Person's Name:

Preferred name:

* Date of Birth:

* Gender:

NHS Number:

Young Person's Mobile Number:

* Address:

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* Postcode:

Email Address:

Young Person's Preferred Method of Contact:

School:

School contact name:

School contact number:

* Young Person's GP Name:

* Young Person's GP Surgery Address:

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* Does the young person have a diagnosed Learning Disability?

Yes No Don't Know

* Does the young person agree to their number being used for questionnaires that help us better understand your needs and how we are helping?

Yes No

* Any Known Allergies:

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Any Long-term Health Conditions?

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* NELFT is a research active trust. Can we contact you about relevant research projects?

Yes No
(Please see https://www.nelft.nhs.uk/c4c for more information)

* Religion:

* Ethnicity:

Language:

Interpreter required:

Yes No Don't Know

Is the young person considered a Child in Need?

Yes No

Is the young person subject to a Child Protection Plan?

Yes No

Is the young person open to Disabled Children’s Social Work Team?

Yes No

Is the young person a Child in Care?

Yes No

Name of the Local Authority who is responsible:

Legal Status under the Children's Act:

Named Social Worker:

Social Worker contact number:

Social Worker email address:

Social Worker Managers Name:

Social Worker Consent obtained:

Yes No

Date they went into care:

Please state the type of Placement they are in:

Please give Keyworker/Managers Name:

Date they went into current placement:

Safeguarding concerns:

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To make a referral for ADHD or Autism Assessment it is mandatory to complete and attach the Family Developmental History form and the Education Observation Profile form. These can be downloaded from the website and take approximately 1 hour to complete. These forms are mandatory for ADHD and Autism referrals.

* Is your referral for (tick all that apply)

ADHD Autism ADHD and Autism Mental Health concerns

* Is the child in education

Yes No

1. Family Developmental History form

2. Education Observation Profile

3. ADHD Observation form

4. Autism Observation form

* Reason for Request for Support:

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* Please describe how this impacts on the young person's behaviour, social development in the school/nursery/college environment:

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* Social/family background:

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Medication:

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* Young Person Outcomes:

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* Parent/Carer Outcomes:

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* Referrer Outcomes:

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* Name of other Professionals/Agencies currently involved, if known:

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Further Comments:

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Kent and Medway Single Point of Access (SPA) Request for Support Form

Referrer Details

Parent/Carer Details