Paediatric Therapies Services Referral Form

Paediatric Therapies Services Referral Form

Surname: / Forename/s
Date of birth: / NHS No: / Interpreter needed? / Yes No

Please circle which service(s) you are referring to:

Occupational Therapy Physiotherapy Speech & Language Therapy

Parental/Family Details

Name of parent/carer:
Relationship to child:
Telephone Numbers: / Home: Mobile: Work:
Address: / Postcode:

Medical Details

GP Surgery:
Relevant medical history including diagnosis:
(e.g. premature, complications at birth, delayed milestones, hospitalisations, dates of any stays in hospital, ear infections)
Is a medical diagnosis being considered? / Yes No (please circle)
If yes, please state:

Involvement with Other Agencies

Does the child have a Child Protection Plan? / Yes No (please circle)
Is the child a looked after child? / Yes No (please circle)
Has this child been referred for a Multi-Disciplinary Assessment (MDA) or Child Assessment service (CAS)? / Yes No (please circle)
Is the child showing a delay across all areas of development/function? / Yes No (please circle)
Is this child known to any other agency? Yes No (please circle)
If yes please identify which service? ………………..…………………………………………….
Audiology / CAMHS/ Education Outreach Services e.g. PSSS, LLS, Portage, EP / Orthoptist /
Orthotic / ENT / HV / Paediatrician / Specialist Nurse for LD / Podiatry/Social Services
Education Details (if attending)
Name of School/Early Years setting: Year Group:
*When does child attend? (if not full-time) (education only) / *Start Date:
*SENCO/Key Worker contact name and number (education only):
*Stage of Code of Practice (education only):
Action / Action Plus / Gathering Evidence for Statutory Assessment/
Statutory assessment/ Statement
*If referring to OT (education only):
Has the OT resource pack been completed? Yes No (please circle)

Reason for Referral (as applicable) - Please describe how the child’s difficulties are affecting their everyday life? What support are the parents seeking?

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Please circle which of the following areas you are concerned about:-

Movement and mobility: sitting, standing, walking, balance, co-ordination, seeks/avoids movement which affects functional activities, need for specialist equipment

Pain: loss of function, decreased range of movement, loss of skills, muscle weakness, asymmetry

Self-care skills: dressing, bathing, toileting, feeding, organising self, independence, excessive sensitivity and discomfort during self-care skills, need for specialist equipment.

Eating and drinking: swallowing difficulties, choking, coughing while eating

Communication: speech sounds, understanding instructions, vocabulary, fluency, spoken language, voice

School tasks: writing, using scissors, participation in PE, maintaining attention

Interaction and Play skills: interest in toys, turn taking, playing with peers, role play, imagination, friendships,

Behaviour: interests, response to changes in routine, aggression, high/low activity level which affects taking part in functional activities, impulsivity, mood, focus on toys/play/school work,

Referrer Details

Name of referrer……………………..…………………Profession………………………………………….
(print name) (e.g. Hosp/GP/HV/School etc)
Signature:……………………………………………………………………………………………………….
Address………………………………………………………………………………………………………….
………………………………………………………………………………………………………………….
Tel No:…………………………………………………. Date of referral:…………………………………..

Consent for Referral

Please tick to confirm you have gained consent from parents/carers for this referral
For school-based initial assessment only (education only):-
Please tick to confirm a ‘school-based initial assessment consent’ form has
been enclosed with this referral.
We are unable to accept this referral without consent from parents/carers.

Health Professionals for school-aged children:- Please note we may need to gather additional information from the educational setting before this referral can be accepted. Please complete the referral as fully as you can.

Education Professionals:- Any incomplete forms may be returned.

Please return to:-

East Locality

– Paediatric Speech and Language Therapy

Community Children’s Centre, East Surrey Hospital, Canada Avenue, Redhill RH1 5RX

Tel: 01737 768 511 ext. 6090 (SLT)

-Paediatric Occupational/Physiotherapy

Therapies Department, East Surrey Hospital, Canada Avenue, Redhill RH1 5RX

/ ext. 6138 (OT) Tel: 01737 231 628 (PT)

North West Locality

– Paediatric Therapies,

The White House, Addlestone Health Centre site, Crouch Oak Lane, Addlestone KT15 2AN

Tel: 01932 826 500

South West Locality

– Paediatric Occupational Therapy/Physiotherapy

The Jarvis Centre, 60 Stoughton Road, Guildford GU1 1LJ

Tel: 01483 783148

-  Paediatric Speech and Language Therapy

Buryfield’s Clinic, 61 Lawn Road, Guildford, GU2 4AX

Tel 01483 783 315

(East & South West Locality - please send a separate copy to each address if referring to SLT and OT/PT)

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