Ordinary Magic Referral Form 
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Ordinary Magic is part of the Connected Care Network which provides holistic care for children and young people across Solihull to meet their physical and mental health needs.  Do you give consent for this child to be part of the network and for a triage call to be undertaken? North Solihull ONLY
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Referrers contact details: - Name, (Organisation if appropriate), Address and Contact details - Including email so we can send you the outcome. *
Do you have consent to make this referral?

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Child's Name
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Child's Date of Birth
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Address child resides at including post code

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The school the child attends - If home schooled or not in education please state.
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If relevant - The Child's Year and Class
Parent/carer details (Name, Address and contact details) - please include all people with parental responsibility. (If you have completed this above because you are self referring you can leave this blank) Without an email address and telephone number we will not be able to make contact.
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Reason for referral 
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Has the child experienced trauma?
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If Yes or Maybe to question 8 please provide details:

Does the child have a disability, do you suspect they may have additional needs or are you awaiting a diagnosis? 
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If Yes to the last question please provide details?
What support do you think would be helpful to the child - If you don't know please leave this blank.

Name and Address of the GP Surgery  the child is registered to
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