Community Children’s Nursing Team and Diana Nursing Team Referral Form Please provide as much information as possible to avoid a delay in processing the referral. Incomplete forms will be returned to the referrer. For assistance in filling out form, please contact the Care Management Centre on 01872 221400 Details: (Or attach a copy of patient file) Name of Child: Date of Birth: Sex: Address: CR Number: NHS Number: ICS Number: Tel Number: Post Code: Mobile Number: Parents - Mother: Father: School: GP: Address: Surgery: Home language: Other Languages: Contact: Number: Interpreter Required: Consent: To be signed by the parent or guardian I give permission for this referral to be made to assess & my child. I also consent to the sharing of information and reports about my child between the teams and other relevant professionals / services, in order for them to provide the most appropriate intervention. Privacy Statement The information you provide is being collected by Children, Schools and Families Early Help Hub (EHH) for the purpose of helping us to make the right decisions about the type of service you need ensuring you receive services best suited to your needs and circumstances This information may also be shared with other relevant professionals in conjunction with the nature of the request or enquiry. The data held relating to the delivery of support by EHH to your child will be used both for the provision of services and also for performance and service planning. This information will be held in a secure environment in line with the Information Governance Alliance Records Management Code of Practice for Health & Social Care 2016, upon reaching the relevant retention the information will be appraised and if relevant destroyed in a secure manner. A full copy of our Trust Privacy Notice can be found at http://www.cornwallft.nhs.uk/about/information-governance/privacy-notice-patients/ Signed: Name: Date: If you DO NOT wish to receive copies of reports about your child please tick: Verbal Consent: (Health Professionals) The referrer has gained verbal consent for: This referral to be made To assess & treat the child
Community Children’s Nursing Team and Diana Nursing Team Referral Form Please provide as much information as possible to avoid a delay in processing the referral. Incomplete forms will be returned to the referrer. For assistance in filling out form, please contact the Care Management Centre on 01872 221400 Details: (Or attach a copy of patient file) Name of Child: Date of Birth: Sex: Address: CR Number: NHS Number: ICS Number: Tel Number: Post Code: Mobile Number: Parents - Mother: Father: School: GP: Address: Surgery: Home language: Other Languages: Contact: Number: Interpreter Required: Consent: To be signed by the parent or guardian I give permission for this referral to be made to assess & my child. I also consent to the sharing of information and reports about my child between the teams and other relevant professionals / services, in order for them to provide the most appropriate intervention. Privacy Statement The information you provide is being collected by Children, Schools and Families Early Help Hub (EHH) for the purpose of helping us to make the right decisions about the type of service you need ensuring you receive services best suited to your needs and circumstances This information may also be shared with other relevant professionals in conjunction with the nature of the request or enquiry. The data held relating to the delivery of support by EHH to your child will be used both for the provision of services and also for performance and service planning. This information will be held in a secure environment in line with the Information Governance Alliance Records Management Code of Practice for Health & Social Care 2016, upon reaching the relevant retention the information will be appraised and if relevant destroyed in a secure manner. A full copy of our Trust Privacy Notice can be found at http://www.cornwallft.nhs.uk/about/information-governance/privacy-notice-patients/ Signed: Name: Date: If you DO NOT wish to receive copies of reports about your child please tick: Verbal Consent: (Health Professionals) The referrer has gained verbal consent for: This referral to be made To assess & treat the child
community-childrens-nursing-team-and-diana-nursing-team.docx