Positive behaviour, Autism, Learning disability, Mental health Service

Good enough referral letter template

Dear PALMS

Generic Opening

I am writing to you to refer (CHILD) to your service for a challenging behaviour /mental health /toileting/sleeping/feeding intervention. I have discussed this referral with the family and they give their consent to this referral being made and through our discussions, I believe that the family are willing to attend and make good use of the service.

I am working with the family in my capacity as the Consultant Paediatrician and I will continue to work with the family. I have been seeing the family in relation to on-going concerns regarding X Y Z.

As you will see from my clinic letter (CHILD)

has been diagnosed with autism or (CHILD) or is on the waitlist for a CDAC assessment and the professionals involved in (CHILD’S) care believe it to be highly likely that CHILD will receive a diagnosis.

has global learning disability / (CHILD) has a diagnosis of global developmental delay where HIS/HER level of functioning is around half that of his chronological age.

Challenging Behaviour Intervention

I am requesting an intervention regarding challenging behaviour at home. At home behaviour presents as

Hitting and punching towards mum and the environment. Behaviour presents as throwing objects at people or the environment. Behaviour presents as frequent swearing and shouting.

These behaviours happen on a daily/weekly basis and cause huge levels of distress and reductions in quality of life for the family. Known triggers towards these behaviours are when (CHILD) is told to come off the Xbox or to transition to tasks that HE/SHE does not want to do such as going to bed. Frequently parents experience that the challenging behaviour happens with the absence of known triggers. These behaviours have been happening for several years however over the more recent past they have increased in frequency since X Y or Z happened.

Currently the impact on the family is significant. (CHILD) is kept out of school for much of the time which is increasing the burden on the family/parents are concerned about siblings mental health as a consequence of behaviour/parents are concerned about family breakdown.

I understand that PALMS is a tier 3 intervention service and that other community based services need to have been tried before accessing PALMS. The following interventions have been accessed by the family.

1) Families in Focus course2) KIDS HUB short break local offer3) 0-25 team allocated worker/social worker4) Speech and language therapy5) Occupational therapy6) Courses run by ADD-vance7) Specialist health visitor intervention8) Currently accessing Carers in Herts9) Robust school based intervention which is implemented at home

OR

Although community level interventions have not been accessed for this family the current levels of challenging behaviour symptoms are so severe that I am concerned that a delay to a possible PALMS intervention for accessing a community level intervention would have a severely detrimental effect on the family with little benefit.

There have been several attempts by the family to address the challenging behaviour which have not been successful in the past and parents emotional well-being is at risk if this behaviour continues.

There are no current child protection concerns. I would however suggest that PALMS clinicians enter the house in pairs as there have been known risks to other professional entering the home from (CHILD).

I trust that this letter will be sufficient to allow this referral to be triaged by your team. If you would like further information then please do not hesitate to contact me on …………………………………………….

Yours sincerely

Referral letter for Mental health

I would like to refer (CHILD) for mental health work. I understand that PALMS is a service for working with children who are unable to access main stream mental health services. As (CHILD) is at a main stream school I naturally referred HIM/HER to CAMHS. However, I believe that after 5 sessions where CAMHS tried reasonable adjustments such as using shorter sessions, using visuals, doing sessions in home HE/SHE still found it very hard to engage with this work. Therefore I am referring to PALMS.

Mental health concerns present in that (CHILD) appears routinely anxious over small demands. Anxiety presents in not talking, verbally shutting down withdrawing to bedroom, telling mum HE/SHE feels scared, has been observed to be shaking which frequently precedes explosive challenging behaviour.

OR

Concerns present around the high level of hand washing that (CHILD) engages in. this leads to the point where their hands are raw and CHILD is often unable to leave the house for significant periods of time whilst engaging in such routines.

Stereotyped and highly ritualised routines are occurring on a daily basis leading to difficulties in the basic family functioning.

OR

(CHILD) presents with very low mood, high levels of apathy, low levels of motivation, has lost interest in things HE/SHE enjoys such as previously playing football and Xbox. Appetite has reduced and HE/SHE has lost weight, sleep pattern has deteriorated with late nights and late mornings refusing to get out of bed.

OR

Parents are growing increasingly concerned that HE/SHE is listening to voices, that HE/SHE is hearing. (CHILD) often appears unresponsive when spoken to and spends much of the time lost in HIS/HER own world.

OR

(CHILD) has presented with thoughts of suicide. On examination I understood these to be realistic thoughts although there is no plan for suicide and there has been incidents’ of self-harm and cutting HIS/HER arm with some broken glass. I recommended that the family access 999 and the CAMHS crisis team next time this happens however as the family are not currently in crisis I ask that your service assess HIM/HER.

OR

(CHILD) has a significant learning disability and is non-verbal therefore I do not believe he will be able to access main stream therapeutic services at CAMHS.

Sample Template- Feeding referral letter

I would like to refer (CHILD) for a feeding intervention with PALMS. I have previously referred to special health visitors and to speech and language therapy for a dysphagia assessment. Please see attached assessment report showing that there is no problem with the swallow or possible aphasia. As you can see from the notes the school health visitor did an intervention however this appears to have not made an impact on the number of foods that (CHILD) will eat or on HIS/HER weight and height.

Currently the impact on the reduction in HIS/HER food intake has meant that HE/SHE is becoming underweight for HIS/HER age which is impacting on HIS/HER health. Current Heights and weights over the last three clinics are: XYZ, leading to as MARSIPAN score of ABC.

I have not referred to a mainstream mental health or eating disorder service because I feel that this is not related to an eating disorder in the classic sense of relating to body image. Parents describe this as an aversion to particular types, textures, tastes, smells of food. (CHILD) is known to be sensory avoiding in many aspects of life including food to the point that this is now becoming detrimental to HIS/HER health.

As well as the health visitor the parents have accessed several courses on eating difficulties for children with autism which they have found helpful to an extent however feel that they would benefit from a more robust focused intervention.

Yours sincerely

Sample Letter – SLEEP referral letter

I would like to refer (CHILD) for a sleep intervention at PALMS currently the level of behaviour created around bedtime is very significant for the family on a daily basis. I believe that this is having a very detrimental impact on (CHILDS) health.

Parents noticed that on the very few occasions that HE/SHE has a good night’s sleep HE/SHE seems more positive and happy the next day. Sleep runs in cycles where HE/SHE will be awake for 72 hours at a time and then crash on the fourth day. Parents have to sleep in shifts in order to stay awake with him and keep him safe.

OR

CHILD appears very reluctant to go to sleep and continually comes downstairs and will only sleep in parent’s bedroom. This has been happening for over 3 years and is having a detrimental impact on the whole family.

Parents have tried many interventions from attending ADD-vance courses on sleep, attending family in focus courses on parenting children with exceptional needs, doing a lot of independent reading on sleep difficulties with a child with autism and working with the special needs health visitor.

These challenges are to the point however where these interventions are not helping. I have prescribed Melatonin and have discussed with the family around sleep hygiene. This has made some small measured difference and would therefore encourage you to assess the family for sleep needs.

Yours sincerely

Sample letter – TOILETING referral letter

I would like to refer (CHILD) for a toileting intervention with PALMS. (CHILD) has struggled to be potty trained several years ago however has recently refused to use the toilet for either passing of urine or stool. (CHILD) has been urinating in the bath and shower and opening his bowels on the floor.

OR

(CHILD) has been hiding faeces around the house.

OR

(CHILD) has been holding faeces for days at a time appearing to be anxious that it will hurt when HE/SHE goes to the toilet leading to diarrhoea overflow and increased levels of constipation.

OR

(CHILD) has been digging and smearing.

I have investigated and found that there are no physiological reasons for the above described difficulties and have prescribed Movicol in order to help (CHILD) to open bowels. School nurse/specialist health visitor have worked with the family to try to prevent the soiling in the bath however this has not been successful. The occupational therapist has assessed the bathroom to see that the bathroom is accessible with (CHILD) physical needs therefore we understand this has a behavioural need related to autism and feel that a behavioural approach from PALMS would be the most effective intervention at this stage.

Yours sincerely