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Bromley Early Support Launch

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					               REFERRAL TO THE BROMLEY EARLY SUPPORT PROGRAMME
Please return this completed form to:
Early Support Administration, Phoenix Children’s Resource Centre, 40 Masons Hill, Bromley, Kent,
BR29JG. Tel: 020 8466 0414 Fax: 020 8466 8855. e-mail: espp.general@phoenixsch.org.uk

 Child’s Name: Forename                                            Surname                         EMS No.
 (please print)

‘The information on pupils with SEN is provided/gathered in accordance with the Data Protection Protocol agreed between
Bromley LEA and the Admissions Authorities within the Borough.’
Everyone working for the LEA, Social Services and NHS has a legal duty to keep information about you and your child confidential.
You may be receiving services from a number of people. So that we can all work together for your child’s benefit, we may need to
share some information. We only ever use or pass on information if people have a genuine need for it. Law strictly controls the
sharing of some types of very sensitive personal information. Anyone who receives information from us is also under a legal duty
to keep it confidential.
‘Health Authorities and National Health Service (NHS) Trusts must inform the parents and the appropriate LEA when they form
the opinion that a child under compulsory school age may have special educational needs.’ Section 332 Education Act 1996


          *Parental signature must be obtained before this referral can be actioned.

 1. Parents’/Carers’ Views
 Do you wish your child to be referred for Joint Assessment?                                        *Yes           No

 Do you agree to share information with Education, Health & Social Services?                        *Yes           No

 Parent’s/Carers’ Signature:                                                                        Date:


 2. Child’s Details
 Date of Birth:                                                   Gender:                            M / F
 Address:                                                         Siblings:

                                                                  Names of Parents/Carers:

                                                                  Child’s First Language:

 Postcode:                                                        Tel. No. (Home)

 e-mail address:                                                  Tel. No. (Work/Mobile)

 Nature of Child’s Difficulties and Summary of Main Needs
 (Diagnosis – if any):
                                                                                       26/03/2006


3. Professionals known to be involved with the Family
           Agency                       Name               Contact Number      Parental Agreement to
                                                                                Invite Professional to
                                                                               Multi-Agency Meeting
G.P.

Health Visitor

Paediatrician

Physiotherapist

Occupational Therapist

Speech and Language Therapist

Children’s Community Nursing Team

Specialist Nurse, e.g.. School Nurse,

Epilepsy, Asthma

Special Needs Health Visiting Team

Specialist Hospital Consultant, e.g.

Neurologist, Opthalmologist,

Audiologist, Oncologist

Dietitian

CAMHS

CFAS

Education, e.g. Pre-School Setting

Sensory Support

Portage

Educational Psychologist

Social Worker

Respite Services

Voluntary Services, e.g. Bromley

Autistic Trust, Family Link, Bromley

Mencap, Petts Wood Playgroup, Scope.

Other



Please attach any relevant reports & detail whether to your knowledge any Initial
Assessments have already been conducted prior to this referral.
Referred By:                                                       Position:
Address:                                                           Tel. Nos./e-mail:

Signature:                                                         Date:

Keywork Co-ordinator informed Paediatrician of referral to Panel   Date:

				
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Description: Bromley Early Support Launch