Beyond Wessex - Southampton Children’s Sleep Disorder Service Referral Form For Referrals From Beyond Wessex

This referral from is for use by paediatricians from beyond the Wessex region,

seeking tertiary or quaternary review,

for narcolepsy

or other rare disorders of central hypersomnolence such as Kleine-Levin Syndrome.

The service is unable to accept referrals for excessive daytime sleepiness secondary to chronic insomnia.

Please complete all relevant details in the form below. Any boxes marked with a star are required before your referral can be submitted.

Referrer's Details
Name*

First NameLast Name
Referring hospital/centre*
Clinician who will provide shared care (including local face to face six monthly clinical review, local prescriptions and local investigations when required)*

First NameLast Name
NHS Email address*
example@example.com

Child's details
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
NHS number*
Address*

Street Address

Street Address Line 2

CityCounty

Postal Code
Telephone Number*
Family contact email address
example@example.com

Details of referral
Clinical history and reason for referral*
Established Diagnoses*
Current Medications*
Investigations*
File Upload (if required for investigations)

Cancelof

Please indicate which of the following suspected diagnoses are present. Please click all that apply and include the requested details/reports when available.

(click each heading for more details)

Suspected Narcolepsy
Excessive daytime sleepinessCataplexySleep related hallucinationsSleep paralysisRecent weight gain

Suspected Kleine-Levin syndrome
Recurrent episodes of excessive sleepiness and sleep duration, each persisting for two days to five weeks. The patient has normal alertness, cognitive function, behaviour, and mood between episodes. At least one of the following is present during episodes: cognitive dysfunction, altered perception, eating disorder (anorexia or hyperphagia) or disinhibited behaviour(such as hypersexuality).

Following submission of this referral for {name13}, it will be reviewed by the Sleep Team and a decision on the need for a clinic appointment made.
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