Referral form for Solihull EYTAC
(Early Years Team around the Child)
Early Years Team (SEND) and Solihull Speech and Language Therapy

Please return completed forms to:
Early Years Team or 
Solihull Inclusion Support Service - Sensory and Physical Impairment Team
email: tacpanelreferrals@solihull.gov.uk
and Speech and Language Therapy
email: paediatric.speechlanguage@nhs.net

If you have any other queries regarding this form, please call: 0121-704-6150. Please note that this form is not for parents/carer(s) to complete.	
Child’s details	
Child’s Name:
	Date of Birth:
     
	Male		☐	
Address: 

Postcode: 

		Female	☐	
	Is this child looked after by local authority?

	YES    ☐              NO     ☐	
	No of children in family: 

	Position of child in family: e.g. 2nd of 3:

Parent/carer/carer details	
Please provide full names and addresses (if different) of each parent/carer(s) responsible for the child. Please indicate who has parental/carer responsibility.	
1. Name:

	2. Name:

Relationship to child:

	Relationship to child:

Address:

Postcode: 	Address:

Postcode: 	
Contact no:           	Contact no:           	
Mobile no:         	Mobile no:         	
Email address:	Email address:
	
Child’s GP details	
Name of GP:                                                              NHS Number:          
	
Address of GP:

Postcode:                     	
Referrer details	
Name and contact details of referrer:

	
Job role: 

	Date: 
	
To be completed if child is attending an Early Years setting (or due to attend soon)	
Name of setting/school:		
Number of hours attending:		
Times attending:		
Name of SENCo/contact details:	
	
Family context: (Please provide any family information that you feel will be helpful including wishes of parent/carer(s). This may include languages spoken by the family)	

	
Please summarise additional information that evidences the child development assessment	
Health
Does the child have:
•	Any existing medical needs?
•	A diagnosis?
•	Any regular medication?
•	A Care Plan? If so please attach
•	Did child pass their newborn hearing screening?	Please explain your information further:

	

Please specify service requested:
Health teams: 	Please
tick	Re-referrals add date returned	
Children’s speech and language therapy 

https://childrenscommunitytherapies.uhb.nhs.uk/speech-and-language-therapy/ 	☐	Date of re-referral:	
Education teams: choose either EY or SPI
			
Early Years Area SENCo – this support is referred through the Solihull early years group setting.
	N/A setting referral	N/A	
Early Years Home Support Service (the Early Years Team) for children with three or more areas of significant difficulty who do not attend a group setting. 
https://www.solihull.gov.uk/Children-and-family-support/localoffer/Early-Years-Team 
OR	☐

OR	Date of re-referral:	
Sensory and Physical Impairment Team (Specialist Inclusion Support Service) and possible Complex Needs Team* referral on if needed.
https://www.solihull.gov.uk/children-and-family-support/localoffer/Sensory-and-physical-impairment-team 
Multi-sensory impairment
Visual impairment
Hearing impairment
Physical disabilities 
*The Solihull Complex Needs Team may be referred to through SISS: SPI where intervention from multiple services are required.	☐	Date of re-referral:	

Re-Referral additional information: completed by __________________ 
Please make and additional information clear (font colour, underline, bold)

Key person if different from above _______________________

Please summarise the main concerns/further actions required through this re-referral…..

	

Please identify other professionals involved with this child	
Professional	Name	Telephone number/
Email address	Base	

Health visitor				

Paediatrician				

Speech and language therapist				

Physiotherapist				

Occupational therapist				

Educational psychologist				

Social worker				

Hospital specialists				

Other				

Please outline the key points from observations and discussion with parent/carer(s):	
Personal, social, and emotional

	Play

	
Communication and language

	Physical development

	
Sensory development

Are there any concerns with vision or hearing?
YES	☐
NO	☐	Independence

	

Child development summaries
To be completed by referrer and supported by other professional involved where possible. Please complete both sections if you can, using your professional judgement and as much information as you have been able to observe.	
Ages and Stages Questionnaire (ASQ) summary 1

Date ASQ was completed: ____________________ Age at assessment (in months):_______

Please indicate cut off levels, as indicated on the final page of the ASQ, in the grid below
    and mark the child’s score x in each area.

Child development ASQ summary
black	
/ / / / / / / / / grey / / / / / / /	
White	

Consider referral 	
Development needs - monitor	
No or low risk	

Area	
0	
5	
10	
15	
20	
25	
30	
35	
40	
45	
50	
55	
60	
Wh/grey/bl	

Communication	

	

	

	

	

Gross motor	

	

	

	

	

Fine motor	

	

	

	

	

Problem solving	

	

	

	

	

Personal and social	

	

	

	

	

	

	

	

	

	

Social and emotional 

Child’s score_______   Cut-off score __________

	

Child development summary 2

Child’s chronological age _________________

Please indicate a best fit judgement [x] for the child’s skills’ level in each area based on your observations, as represented by the 6-month age banding. This will show a child’s area of difficulty and the significance of the developmental delay.

3 - 3 ½ years	

	

2 ½ - 3 years	

	

2 - 2 ½ years	

	

1 ½ - 2 years	

	

1 – 1 ½ years	

	

6mths – 12 mths	

	

0 to 6 months	

	

Represents ‘typical’ development level milestones	
Personal, social and emotional	
Communication and language	
Physical development	
Play	
Independence	

	

The following factors will delay the referral process:
•	Incomplete information provided
•	Inability to authenticate current address and phone numbers
Please Note:
•	The person referring the child/young person must be of a professional nature i.e. health visitor, doctor, paediatrician, nurse, SEND practitioner etc. Parent/carer(s) cannot refer their child directly through this form.
•	Parent/carer(s) consent: No referral will be accepted without consent.	
PARENT/CARER CONSENT FORM
Any information that you provide will be used by local authority/health services to help us tailor services for your child. Your information will be treated as confidential and stored in a secure way. It will only be shared with other council services and partner organisations to ensure our records are kept accurate. The staff from the team working with your child will report on assessment and/or intervention findings and discuss with you and the school/nursery the action and support which will need to be followed.

We may also need to share your information for the prevention and detection of fraud and/or other crimes or as the law requires. For further information about how we use your information please refer to the Council’s privacy statement on www.solihull.gov.uk or contact eyenquiries@solihull.gov.uk.

Your records will be kept for 25 years for audit purposes and in the event we need to provide information about the service you have received. 
  Yes		No
•	I confirm I understand why you want my information and I have had the opportunity to consider this.	☐		☐

•	I agree that the information will be shared with other professionals who are already involved with my child, or other agencies that may become involved in the course of any support offered to my child. This will be done in accordance with Solihull’s MBC information sharing protocols. This will only be information that is relevant and necessary and will only be shared with people who need that information at that time. 	☐		☐

•	I understand I can opt out and withdraw my consent at any time by contacting the Early Years Team on 0121 704 6150 or via email at eyenquiries@solihull.gov.uk	☐		☐

•	I give consent for you to record and hold my information for the purposes explained to me.	☐		☐

•	I confirm that everyone who qualifies as a “parent” under education law is aware of this application and agrees with the content.	☐		☐

Name of parent/carer: 								 (please print) 

Signature: 								__________________

Email address: 										__

Date: 				

If consent is received via phone/e-mail, then the referrer is confirming that the parent/carer has agreed to all the above actions. The referrer is accountable for the parent/carer agreement to store information and pass information on to referred services.
---------------------------------------------------------------------------------------------------------------------------Where a child is re-referred the parent/carer must agree to further referrals

Name of parent/carer: 								 (please print) 

Signature: 								__________________

Date: 				

Referral request for: ____________________________________________________