Client details

Client Name *

Date of birth *

NHS number *

Address *

Telephone number *

Alternative contact details

GP details

GP name *

GP address *

Midwife name *

Midwife mobile number *

Details of other professionals involved

Pregnancy details

Expected date of delivery *

Details of any previous pregnancies

Referral details

Main areas identified for additional interventions *

Any other information to support your referral

Referral details 2

Please tick the boxes that are relevant to your referral. Please tick where it applies to either parent. Please tick as many as apply.

Looked After Child or Care Leaver client/partner *

Yes

Learning need client (autism/ADHD) *

Yes

Domestic violence (personal and as part of family life when a child / ACE) *

Yes

Mental Health History (significant/ recent/ long standing/ intervention) *

Yes

Alcohol/substance misuse (personal and as part of family life when a child / ACE) *

Yes

Difficult parenting history (has been under social care / ACE) *

Yes

Previous children / child removed *

Yes

Known to other services (e.g. probation / justice system) *

Yes

Aged 17 or under *

Yes

Homelessness *

Yes

Baby child protection / pre-birth assessment *

Yes

Unsafe home environment *

Yes

Child Sexual Exploitation / Child Criminal Exploitation *

Yes

Poor family support *

Yes

NEET - Not in Education, Employment or Training *

Yes

Poor engagement *

Yes

Parental conflict issues *

Yes

Poor health or poor management of health condition/ lots of A&E attendances *

Yes

Referral details 3

Name of referrer *

Job title (referrer) *

Email address for referrer *

Family Health Team