Single Point Of Entry Referral Form - Virgin Care

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Bath and North East Somerset Single Point of Entry Referral Form
This form is also available as
Please return this form, completed as fully
as possible, to:
a Word template.
SPE Administrator
Child Health Department
Room 47
Please contact the SPE
Bath NHS House
administrator if you would like
Newbridge Hill, Bath
a copy of this.
BA1 3QE
Tel: 01225 731575
Fax: 01225 731580
Details of Child
Or attach label. Leave this section blank if these details are on an accompanying letter.
Child's Surname:________ Forenames _________________
Date of Birth _______Family name if different to child's ____________________
NHS No: ____________
Ethnicity _______ First language _________________
Address_____________________________________________________
______________________________________________________________________________________________________
Post code _____________________________________ School / Pre-School _______________________________________
Mobile ______________________
Home telephone ______________________ Evening telephone ___________________
Child's GP _________________________________ GP contact details ____________________________________________
Health Visitor/school nurse(if known)_________________________________________________________________________
Referral to:
These are the teams currently accepting referrals through the B&NES Single Point of Entry System.
If you are not sure where your referral should go, please refer to the Intake Team.
A team of clinicians will discuss the referral and ensure it is passed to an appropriate team.
Referrals from Schools:
Please ensure you discuss your referral with the school nurse or educational psychologist. They may be able to help the
child, seeking advice from professionals within the locality team, without the need for a full referral. Discussed with school nurse / educational
psychologist?
Yes
No
Paediatrician
Continence Service
Dietician
CAMHS (check new referral criteria)
Speech and Language Therapy
Occupational Therapy
Children’s Learning Disability
Physiotherapy
Nursing Service
School Nursing Service
Audiology
Orthoptist
Intake Team
BANES SPE RF 2 08/02/17
1

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