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

* Verbal consent obtained from the young person I agree to the referrer completing this Request for Support and to be contacted by a clinician to discuss my needs:

Yes No

* Please give reasons as to why the young person has not consented to this Request for Support:

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* Verbal consent obtained from parent/carer. I agree to the referrer completing this Request for Support and to be contacted by a clinician to discuss my young person's needs:

Yes No Not required young person 16+

We cannot accept any Requests for Support without consent from the parent/carer or young person (where appropriate). If you wish to discuss this further please call 0800 0113474.

Referrer Details

* 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

Please provide documents relating other professionals’ involvement with the young person.

1. Core Assessment

2. Chronology

3. SDQ results

4. Other

* 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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What happens to your information?
If you would like to find out what happens to personal information held about you, please read our privacy policy for more information:
https://www.nelft.nhs.uk/download.cfm?ver=1014