CHILDREN’S OCCUPATIONAL THERAPY DEPARTMENT, PHOENIX CHILDREN'S RESOURCE CENTRE,
40 MASONS HILL, BROMLEY BR2 9JG. 020 8466 9988 OT Direct Line: 020 8315 4697 Fax: 020 8466 8855
Email:
Name of child: / Name of main carer/s:
DOB: Gender: M / F
Address: / Carer consent to Referral: Yes / No
Interpreter needed? Yes / No
Language: / Language:
Home tel: / Is this child a Looked After Child? Yes / No
Social Worker:
Mobile:
Work tel: / Ethnicity:
School/Pre-school/Nursery:
Address:
Tel: / GP:
Address:
Tel:
Does the child have an EHC or receiving additional support?
Diagnoses:
IF ALL SECTIONS ARE NOT COMPLETED THE REFERRAL WILL BE DECLINED
Our service aims to provide a child centred, needs-led provision which is based upon children’s performance of everyday activities of self-care, school work, and leisure/play.
The service is open to children & young people between 0 – 18 years of age (19 if still in full time education)
with a Bromley GP who meet the following criteria:
- Children with physical disabilities/conditions or co-ordination difficulties, which have a significantimpact upon participation in everyday occupations (self-care, school work or play)
- This does not include when learning or social communication difficulties are the main barriers to the child achieving age appropriate functional independence
- Children who attend Marjorie McClure and Riversideschools are not required to have a Bromley GP
- Children closed to the service during the last 24 months, requiring brief revision of input previously provided
REASON FOR REFERRAL
WHATdo you want to achieve from the OCCUPATIONAL THERAPY assessment?
Other relevant information: e.g. social situation, safeguarding concerns, any perceived risks
Main Areas of Difficulty / Comment on Child’s Performance
MUST COMPLETE / Strategies previously tried
MUST COMPLETE
Handwriting/Prewriting/Drawing Skills
Presentation & organisation of work & materials i.e. Maths
Tool Use (e.g. pencil, scissors, etc)
Manipulatory skills (e.g. threading, stacking, screwing etc)
Dressing (e.g. laces, buttons, fastenings)
Toileting (e.g. getting on/off toilet, management of clothing, wiping)
Eating (e.g. using knife and fork)
Negotiating obstacles and people
Balance & climbing on equipment
Ability to learn new movement skills & games
Catching/throwing ball
Seated posture/seating
Avoidance of handling different textures
Following directions
Attention & listening
Play/Social Skills
OTHER please outline any other areas of development the child is having difficulty in or is delayed in
Name of Referrer:
Designation: / Signature:
Date:
Location: / Tel No:
Name of Parent/Carer:
Consent given for assessment and treatment
Parent/Carer Signature:
Date:
Tel No:
We may need to contact school. If you do not wish us to do this please tick the box
We may telephone you at home. If you do not wish us to do this please tick the box
We may need to leave a message on the answer phone.If you do not wish us to do this please tick the box