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Children's therapy

Community child health - referral form

Before you begin this referral form, please ensure you have completed all additional forms required for your referral. If there are, please download them, fill them in and save them as a PDF before you start. If you do not your form may time out and you will lose what you have entered

Additional forms can be found at the links below -

Indigo pathway - diagnostic pathway for ASD and ADHD
School report >
Sensory questionnaire (parents) >
Strengths and difficulties (parent) >
Strengths and difficulties (teacher) >

Community children'snursing
Nursing referral >

Joint feeding clinic
Joint feeding referral >

Occupational therapy - pre-school
Occupational therapy referral >

Podiatry referral >

Speech and Language Therapy – pre-school
Pre-school referral>

Speech and Language Therapy – school aged
Quick observation based assessment >
Speech checklist >


Please note that referrals will only be accepted if the child or young person is registered with a Medway GP and lives in Medway

All referrals are triaged and children will be seen by the most appropriate professional – this may not be the person you have requested initially.

To find out how we use this information, our security and your rights visit our privacy page >

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Does the family need an interpreter? * required

Visual impairment: * required

Hearing imapairment: * required

What other service involvement have they had?

For schools use only
Do you currently buy in our traded services (MCH+):

If yes, and the referral is not accepted under NHS criteria, do you want the child to be seen under your traded contract?

Does the child have an EHCP?

Child protection plan:

Child in need:

Known to social services disabilities team:

Looked after child:

Has early help been initiated?

Intervention and outcome
Are parents aware of this referral:
(If no, we will be unable to proceed with the referral)


Please tick the service you are requesting and complete all the associated forms. All additional information must be attached with the referral. Any omissions will result in the referral being rejected.

Note secondary pupils must be referred to NELFT Emotional and Wellbeing service Please note when making referrals to the Indigo pathway we require all 5 forms to be completed. Once received, we will triage and place the child on the appropriate pathway. GPs should ask parents to discuss their concerns in the first instance with the school who will then complete the forms and refer on. If for any reason this is not possible we will accept a GP referral without the supporting evidence but parents will need to be informed that there will be a delay in processing while we collect the information.

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