Requesting school nursing support (for a child or young person) :: Dorset HealthCare University NHS Foundation Trust

Child/young person's name Required

Date of birth Required

NHS number (if known)

School - child / young person attending? Required

If not in school, please give the reason

Parent/carer email address

Parent/carer phone number

It is important that all of the following questions are answered to provide a clear picture of your concerns. Once your request for support is received, it will be triaged and appropriate actions taken, which could include: signposting, allocation to a member of the team or rejection (in the event of a rejection we will provide the referrer with a reason for this).

If you have answered 'No' to either of the above, please explain why

Where necessary, if a conversation with parent/carer is required, we will contact you to discuss. If this Request for Support is accepted and we need to see or speak to a CYP this will either be via a face to face to face appointment in school or a virtual video consultation appointment.

How would the child/young person/parent/carer like to be contacted? Required

Parental/carer consent given by (name): Required

Does the person named above have parental responsibility? Required

Consent from parent/carer is always required for children in year groups R-6 inclusive.

Reason for request for support Required

Which interventions have already been tried?

What would you like the support from our service to achieve?

Does the CYP have any additional education or health needs? Required

Other agencies involved:

Support requested by Required

Date of Request for Support Required

Requester's contact details: Required

Relationship to child Required

Requesting school nursing support (for a child or young person)

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