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Referral for Circle of Security Parenting (COSP) Group
Home
Services
Parent and Infant Relationship
For parents/primary care givers
Circle of Security Parenting Group for parents
Referral for Circle of Security Parenting (COSP) Group
Source of referral
Full name
Email
Consent MUST be obtained. It is important that the referrer explains that the family’s information will be shared & discussed with colleagues in CAMHS who co-deliver this group. Please tick to confirm consent has been obtained.
Yes
Family Details
Child's Details
Child's Name
NHS number
Ethnicity
Date of Birth
Date
Child must no be over the age of 5 years old
Address
Address 1
Address 2
City
Country
Select a country
United Kingdom
County
Postal Code
Caregiver's Details
Name of main carer and relationship to child
Date of Birth
Date
NHS number
Phone number
Ethnicity
Name of main carer and relationship to child
Date of Birth
Date
NHS number
Phone number
Ethnicity
Considerations
Childcare? If YES*: please ensure parent is able to arrange suitable childcare for all sessions and commit to attending all 10 sessions?
Yes
No
Other children in the family?
Yes
No
Other services currently involved? if yes please provide details
Any current safeguarding concerns? If yes please provide details
Can the parent get to and from the venue (public transport/ have own transport)?
Are the parents able to think about their own parenting and feel safe to do so?
Does the parent identify as current challenges of parenting? What are their goals/ hopes?
Paperwork Completed/provided
MORS
Yes
No
N/A
PHQ9 & GAD7
Yes
No
N/A
PaIRS/ CAMHS Information sharing and storage
Yes
No
N/A
PaIRS/ CAMHS Consent
Yes
No
CoS Evaluation consent
Yes
No
N/A
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