0-19 Referral Form

Please select from the following before proceeding

Start new referral
Retrieve previous referral progress

Please complete this form, as fully as possible, with relevant information and details to support the referral.

*Spam Guard: What is 12 + 5?

Section 1 - Referrer's Information

* Legal first name

*Legal surname

*E-Mail Address

*Job Title/Role

*Agency/Organisation

*First line of address

*Town

*Postcode

*Contact Number

*Is this referral for yourself?

Section 2 - Key information about the Patient

* Legal first name of child/young person

*Legal surname of child/young person

Middle name(s) of child/young person

Other name(s) child is known by

*Gender

*Date of Birth

Ethnicity

GP Name

GP Surgery

*Do you consider this referral is high priority?

Please Note: We only accept referrals for under 18 years of age

NHS No (if known), must be 10 digits

Section 3 - Reason for Referral

Please indicate the referral reason you think best aligns to support the needs of the child/young person.
For all Infant Feeding referrals and referrals to Specialist Children's Services please refer to The Children's and Young People's Referral Management Centre: Referral Management Centre | NHFT

Referral Reason Priority	Referral Reason
*1st Reason

Thank you for submitting a referral. Your response has been recorded.

DATA PROTECTION NOTICE

Data that you provide to the Trust is processed in accordance with the Data Protection Act 2018, please see the Trust Privacy Notice for further information on how data is used:

https://www.nhft.nhs.uk/privacy/

	Yes	No	Unknown
*Is an interpreter required?
*Is a signer required?
Is the child/young person a Looked After Child or Adopted?
Does the child/young person have an Education Heath and Care (EHC) Plan?
Does the child/young person have a disability?
Are there any safeguarding concerns?
If there is a safeguarding concern is the child/young person currently the subject of a Child Protection or Child in Need plan?

NHFT Referral Forms

0-19 Referral Form

Please select from the following before proceeding

Section 1 - Referrer's Information

Section 2 - Key information about the Patient

Please Note: We only accept referrals for under 18 years of age

Section 3 - Reason for Referral

Section 4 - Consent

Section 5 - Information about the Child/Young Person

Supporting Information

Section 6 - Professionals involved

Section 7 - Referral Information

Attachments

Thank you for submitting a referral. Your response has been recorded.