Torfaen Pre-Birth Service — Referral Form

For partner agencies referring a family to the Crystal Pathways Torfaen Pre-Birth Service. Please complete all sections as fully as possible. Incomplete referrals may delay allocation. If you are uncertain about any field, please include a note rather than leaving it blank.

Data protection: All information in this form is handled in accordance with UK GDPR, the Data Protection Act 2018 and Crystal Pathways’ information governance policy. This form is transmitted securely to the Crystal Pathways clinical team and is not distributed onward without consent.

Referrer details

The professional making this referral

Referrer full name *

Job title / role

Organisation

Team / department

Phone number

Email address *

Date of referral

Referral sent to (CP contact)

Parent / client details

The parent(s) being referred — include both parents if referring a couple

Full name(s) *

Date(s) of birth

Address(es)

Phone number

Safe to call?

Yes No

Email address

Safe to contact by email?

Yes No

Preferred contact method and times

Interpreter required? (Yes / No — if yes, state language)

Primary language

NHS number (if known)

National Insurance number (if known)

Pregnancy details

Current gestational age (weeks) *

Expected due date *

Previous pregnancies (incl. miscarriages & terminations) *

Previous live births *

Children currently in parental care *

Previous children removed from care *

Midwifery team / named midwife

Hospital / maternity unit

Next antenatal appointment date

Is there a pre-birth plan in place?

Yes No In progress

Child Protection Plan in place? (Yes / No — if yes, state category)

Care proceedings underway or planned?

Yes No Unknown

Risk & presenting needs

Indicate known or suspected risks and concerns; add brief notes where relevant

Additional risk / needs information not captured above — include anything relevant to safe allocation, first contact, or risk management

Current services involved

List all services currently involved, with worker names and contact details where known

Service / agency

Named worker

Phone / email

Reason for referral

Please describe why you are referring this family to Crystal Pathways and what you hope the service will provide * — be as specific as possible; generic referrals may be returned for clarification

What does the parent know about this referral? Have they consented? — consent is required before referral unless there is an immediate safeguarding concern

Is there anything about this family that the receiving practitioner needs to know before making first contact? — e.g. safe contact arrangements, known triggers, access issues, risk to practitioner

Urgency & priority

Please select the appropriate urgency level

Urgent (within 48 hours)

Immediate safeguarding concern; birth is imminent; acute crisis

Priority (within 5 working days)

High risk but stable; significant vulnerability; third trimester

Routine (within 10 working days)

Early intervention; second trimester or earlier; lower risk profile

If urgent: please describe the specific concern or trigger

Referrer declaration

I confirm that the information provided in this referral is accurate to the best of my knowledge. I confirm that the parent / client has been informed of this referral and has given consent, or that an immediate safeguarding concern justifies the referral without consent. I understand that this information will be stored securely by Crystal Pathways and used to support the delivery of the Torfaen Pre-Birth Service.

Signature (type your full name) *

Date

Print name

Job title

Something went wrong and your referral was not sent. Please try again or contact Crystal Pathways at admin@crystalpathways.co.uk.

Your referral will be sent securely to the Crystal Pathways Torfaen Pre-Birth Service team. By submitting you confirm the declaration above. Please do not send case information by unencrypted email.

✓

Thank you — your referral has been received

Your referral has been sent securely to the Crystal Pathways Torfaen Pre-Birth Service team. We will review it and contact you if any clarification is needed. Urgent referrals are reviewed within 48 hours.

If you have any questions, please contact us at admin@crystalpathways.co.uk.