This referral has NOT been sent yet. You will be redirected to the listing's external referral form. Please complete the referral form there to submit the referral confirm Details Connected Care Network by Connected Care Network Who is this referral for? I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria "Please check that the child/young person being referred is registered with one of the following surgeries : – Arran Medical Centre - Sheldon Heath Medical Centre - Bosworth Medical Centre - Chester Road Surgery - The Castle Practice - Croft Medical Centre - Kingshurst Medical Practice - Coventry Road Practice - Sheldon Heath Road Surgery - Green Lane Surgery - Manor House Lane Surgery - Marston Green Surgery - Parkfield Medical Centre - Rowlands Road Surgery" Your Details Email Email is invalid We already have an account with this email. Please log in. Password Reset my password Log in First name Last name Your relationship to the person Organisation name Who are you referring? First name Last name Known as Date of birth Email Don't know / client doesn't have an email address Phone Address Line 1 Address Line 2 Town/City Postcode GP surgery NHS number Ethnicity SelectEnglish, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Any other White backgroundWhite and Black Caribbean White and Black African White and Asian Any other Mixed or Multiple ethnic backgroundIndian Pakistani Bangladeshi Chinese Any other Asian backgroundAfrican Caribbean Any other Black, African or Caribbean backgroundArab Any other ethnic groupPrefer not to say Gender SelectFemale Male Transgender female Transgender male Non-binary Intersex Not specified Not known Other Additional referral details Do not enter protected health information (PHI) or any other personal data in these fields. Please share some brief details regarding this referral Do you have the parent/carer's consent to make this referral? - If you do not please call us to discuss this further. Yes No Parent/carer's full name & relationship Please select if any of the statements below are correct for the Child/Young person Not in Education Employment or Training School attendance below 90% Impacted by Domestic Violence At risk of Offending Impacted by Substance Misuse Has a Disability or a Special Educational Need Issues with Housing or Finances Concerns around mental or physical health Parental/family Mental or Physical Heath issues impacting the child Single parent/carer family This field is required. Tell The Story Once: Please tell us in a paragraph or two the child's story - (dates are very helpful if you also have them) Please list any other agencies that are involved including contact details. Does the child have a Plan? ie EHCP, CP, CIN, LAC What school do they attend? Does the child qualify for HAF funding? Please state code if known Confirmation and consent Tick to confirm you have gained consent to share this information with the service provider, your organisation and Joy Tick to confirm the service provider can directly contact the client Would you like to create an account? Make referrals faster next time you use Joy. Registered users can message service providers, submit reviews and track the progress of their referrals online. Password Weak password! Use at least 8 characters Use upper and lowercase characters (a-z) Use 1 or more numbers (0-9) Confirm password Please enter the same value again. required Submit Email: Password: Email
