Occupational Therapy Referral Form

We have been advised that you may benefit from an Occupational Therapy Assessment. Please complete this form FULLY and as CLEARLY as possible. The information will help us determine if you meet the criteria for our service and if so, the urgency of your needs and enable us to process the referral quickly – otherwise the process will be delayed.

Once completed, please post, fax or email this form to: The Access Service

Calshot Community Care Centre

57 Calshot Street

London N1 9XH

Telephone: 0207 527 2299 Fax: 0207 527 5114 Email:

Your Details
Title: / Gender: Male Female
First Name:
Family Name: / Address:
Date of Birth:
Telephone numbers:
Your Landline: / Your Mobile:
How would you like to be contacted? / Email address:
Ethnic Origin: / Do you need an interpreter?
If so what Language?
Do you live alone?
If ‘No’ who do you live with?
Are you a carer for someone? / Do you receive help from the person you live with? If yes please state what type of help.
Your property: Who owns your home?
Which floor do you live on?
Medical Information: Diagnosis / disability

Do you have a visual impairment

/ Do you have a hearing impairment

Are you incontinent of urine?

/ Are you incontinent of faeces?

GP name and address:

GP Tel number:
Reasons for Referral (please state what you are having difficulty with)
Mobility

Do you use any walking equipment indoors?

Do you have stairs to your property?

If you have difficulty with the stairs, do you think additional rails would help you?

Do you have difficulty getting in and out of your property?

If ‘yes’ please give details:

Do you think a rail, or other adaptation at the front of your property, would help?

Are you able to go outdoors?

If ‘yes’, please tick the following:

Able to use bus: Family/friend take me out:
Taxi card: Own a car:
Activities of Daily Living
Chair Transfers:
Are you able to sit down on your armchair?
Are you able to get up from your armchair?
If your chair is too low, do you think a chair raise would help?
Bed Transfers
Are you able to get into bed?
Are you able to get out of bed?
Are you able to sit up in bed?
If your bed is too low, do you think a bed raise would help?
Toilet Transfers:
Are you able to sit down on your toilet?
Are you able to stand up from your toilet?
If you have difficulty, do you think a grab rail by the toilet would help?
If the toilet is low, do you think a raised toilet seat would help?
Bath Transfers:
If you are having difficulty, please describe how you get in and out of the bath?
Does anyone assist with bathing at present? Please give details:
Please state what bath equipment or adaptation you have at present, and why they are not helpful?
Please list all other equipment and adaptations at your property

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If you have completed this form on behalf on the person wishing to be assessed, please complete this section

Your name:

/ Telephone number:

Relationship to the person referred:

Is the person aware of the referral?
Please use this space to provide any other relevant information
Thank you for completing this form. Please add your name & date to indicate details are correct.

Referrer’s name: Date referral completed:

The OT Team work within the Fair Access to Care guidance criteria

A member of the OT Team will assess the difficulties the person, or carers are having and will try to find solutions where possible. The team can offer advice on alternative ways to carry out tasks and may recommend specialist equipment and adaptations if considered appropriate.

Please note:
The OT Team does not provide furniture such as: high back armchairs, standard beds, standard mattresses, orthopaedic mattresses etc. If you need these and other household items at affordable rates, please contact the ‘Restore Community Project on 0208 493 0900.
If you need to be assessed for a wheelchair, please discuss this with your GP who will refer you to the Wheelchair Service 0203 317 5040.
If you need to be rehoused, please contact Housing on 0207 527 4140. The Housing Team will refer you to the OT Team for an OT housing report, if they feel there is a need for one.

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