Child Exploitation Nurse Referral Form

Please note the role of child exploitation nurse is to support with health needs for those children who are at risk of or vulnerable to exploitation with a focus on preventative work.

If you would like to discuss any individual cases, please contact the team on [email protected].

Eligibility criteria

Has a full child exploitation screening tool been completed?(Required)

If yes, what is their current level of vulnerability risk(Required)

Is there a current safeguarding plan?

Please add any comments

Education(Required)

Please include the name of the school

Contact details of lead professional/social worker/family service worker

Name(Required)

First Last

Contact telephone number(Required)

Email address

Learning or physical disabilities(Required)

Please add any comments

Previous or current mental health concerns(Required)

Please add any comments

Previous or current drugs and or alcohol misuse(Required)

Please add any comments

Has the child experienced any ACEs (Adverse Childhood Experiences)(Required)

ACES include: physical abuse, sexual abuse, verbal abuse, emotional neglect, physical neglect, parental alcohol, drug misuse, parents with mental health problems, domestic abuse, adults who have spent time in prison, parents separated, parental bereavement, bullying, poverty.

Please add any comments

Client details

Name(Required)

First Last

Date of birth(Required)

Day/Month/Year

NHS Number (if known)

Ethnicity(Required)

Address(Required)

Street Address Address Line 2 City County Postcode

Email(Required)

Contact telephone number

Contacting the client

Client consent to text(Required)

Client consent to leave a message(Required)

Parent/Guardian details

Name(Required)

First Last

Date of birth(Required)

dd/mm/yyyy

Ethnicity(Required)

Name of professional making the referral(Required)

First Last

Position held(Required)

Contact telephone number(Required)

Supporting multi-disciplinary information

Drop files here or

Max. file size: 50 MB, Max. files: 2.

Additional information

Further relevant information

Eligibility criteria

Contact details of lead professional/social worker/family service worker

Client details

Contacting the client

Parent/Guardian details

Trust Headquarters

Telephone

Services

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Child Exploitation Nurse Referral Form

Eligibility criteria

Contact details of lead professional/social worker/family service worker

Client details

Contacting the client

Parent/Guardian details