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Children's therapy

Children's therapy - Referral form

Referrals can be made by a GP, health visitor or school using the form below.

Please attach any relevant reports and/or assessments along with the following required appendices, which should be completed in consultation with parents (as appropriate);

Please note that clinic letters can be accepted if they contain all of the required information as listed on the appendices and referral highlights which services are required.

There is no appendix required for musculoskeletal physiotherapy, or podiatry.

Child's details
* required
* required
* required
   
Gender: * required


* required

Parent/carer/guardian details
* required
* required
* required
* required
Nursery/school details




GP details
* required
* required

Visual impairmant: * required


Hearing impairment: * required


Speech communication: * required



* required

* required
Safeguarding information
Child protection plan: * required


Child in need: * required


Known to social services disabilities team: * required


Looked after child: * required





Other details
Has this child been referred to us in the past?: * required



* required
Please list the main concerns/functional difficulties observed at home/at school and describe how they impact on their life. (Please note poor speech or poor motor skills is not specific enough, we need to be able to judge the severity of the difficulties by how these difficulties affect the child's life; for an OT referral to be accepted the child will need to have 3 functional difficulties which impact on daily life.)








Please note: all referrals require parental/guardian/carer consent or we are unable to proceed.
Has this referral been discussed with parents?: * required


Are parents in agreement with this referral?: * required


Referrer details
* required
* required
* required

* required

You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

* required
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