Referral to the WellChild NurseIf you have a question about this form or need help please contact Nina Griffiths on 0300 421 8299Step 1 of 333%If you have a question about this form or need help please contact Nina Griffiths on 0300 421 8969 Tell us about the childName of Child * REQUIREDGender * REQUIREDMaleFemaleDate of Birth * REQUIREDDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NHS NumberAddress * REQUIREDPostcode * REQUIRED Tell us about the child's familyName * REQUIREDRelationship to childHome telephoneMobile telephoneTell us who provides care for this childConsultantContact numberContact email GPContact numberContact email Social worker or lead professionalContact numberContact email Other Agencies involved in Care(Please provide contact details where available)Tell us about the child's diagnosis and the reason for this referralWhat is the medical diagnosis?Referral criteria 1Please selectProlonged inpatient care at level 3/4;Tertiary care managed by 2 or more specialist teams; Tertiary care managed by 1 specialist team but with health complicationsYP condition is complex to manage – organ transplant, complex multisystem condition, acquired brain injury, significantly life limitingReferral criteria 2Please selectNo clear overriding diagnosis for which accounts for all the medical conditions and/or ongoing conflict around the assessment or care plan for conditionRequires a central point of communication to guide and support a family through transition points e.g. From hospital to home or between servicesChild/YP not engaging with education and/or no discernible consistent understanding of YP educational needsSocial concerns such as housing, economic situation or parental capacity to manage conditionTell us about yourselfYour name * REQUIREDYour contact number * REQUIREDYour email * REQUIRED Tell us about consent for this referralHave parents or carers consented to this referral? * REQUIREDYesNoDo we have consent to share information? * REQUIREDYesNo
